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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Pro ram at Existin Facilit F P o f 2. 0New EH Pro ram and New Facilit <br />Facility ID oD24g72-- Program Record ID 34 7 7//0 - l„ <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br /> <br /> 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # (pi 2"-2- C.:r3 Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0A013 <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br /> O Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of units) 0 Dumpsters > 20 cu yd (# of Units) <br /> O CIA Land?' <br />Farm/R <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 81W JOA <br />EA Qtl EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM H 111iN COEAL, ROAtitiE, ONTy• <br />CONTACT PERSON Day Ph Night Ph 18 DEPAporY,..rAL -‘,fticiv <br />0 Surcharge FEE 0 Other FEE <br /> to (2 3(12.-1 0 Food Handler <br />Date 2S INVOICE # oi <br />ACCOUNTING OFFICE U37j. Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />vo0c1A/u <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />VEVA„rt <br />Nursing 0 Large Generator 0 Small Generator DAp,ted Hauftstia <br />044e2Orj <br />PROGRAM ELEMENT LO ;LP FEE <br />INSPECTOR # 4183.g PERMIT VALID <br />Iheck # AMOUNT PAID <br />kff(Cash$10-1-: REVIEWED B