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o Surch rge FEE <br />to <br />Date <br />REVIEWED BY /) ACCOUNTING OFFIC 9- <br />PROGRAM ELEMENT `; FEE <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />Cash <br />0 Other FEE <br />0 Food Handler <br />INVOICE # <br />Date <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facilit <br /> ONew EH Program and New Facilit <br />Facility ID <br /> <br />Program Record ID PRDSL-1-qp,31 <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 Square Footage Food Handlers Course required: YES LI No CI <br />Commissary 0 Dry storage only 0 with Food Preparation 0Vending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Special Event---Dates of operation from <br />9 --)..._7- -2A ---t-(7) --.k..- 7--2- -7—,:).- Lk 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0A0B <br />,Temporary Food Facility --Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI 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 />0 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 LI 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 LI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />0 Body Art Facility-S <br />LI <br />WALR Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art-Temp Even% Fte ralcilitt (4131) <br />pArENT <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />0 Package Treatment Plant Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br /> O Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility <br /> O Process/Recycle Facility <br />Refuse Vehicles (# of Units) <br /> <br />O Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Night Ph glO CONTACT PERSON cb (f\ Day Ph <br />48-02-034 MASTERFILE RECORD INFO MATION PINK <br />License # Sticker # <br /> License # Capacity ck <br />2024 <br />0 Chemical Toilets ----Number tialibgaulN COUNTY <br />ENVIRONMENTAL <br />ICNRAMATeMEN1 <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />1/23/13