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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Facility ID n Facility Add Record ID and New (Please check the appropriate description and specify size, number of units and pertinent information.', FOOD PROGRAM (1600) ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes Lg /V7 U ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program El Program 1 Facility El Program 2 Facility El ElHazardous Waste Generator (2200) ---------- >-Tons Generated Per Year 11Tiered Permitting Facility -------> ❑ CA (2232) ElCE (22333 2234, 2235, 2237) El[IAboveground Storage Tank Facility (AST) (2800) Number of ASTs 11Underground Storage Tank Program (UST) (2300) Use USTA and B forms ElOther CUPA Program Program 3 Facility PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) LiHotel/Motel ------ Number of Units L.1Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee HousinplLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment L1UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site 11UIC Site ❑ Abandoned HW Site Elnon-NPUSEP Cleanup Site ElRWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ElPoultry Farm -------Maximum number of birds_ TATTOO. BODY PIERCING, ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) Body Art Facility -Single Use (4120) ElBody Art Facility -Sterilization (4121) ElBody Art Temp Event Co-ord (4130) ElBody Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper VehicleRegistration # License # Capacity Vehicle # 1:1Pumper Yard 11Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ElLandfill El Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site L1Waste Tire Facility ElCompost Facility ElProcess/Recycle Facility ElCIA Landfill Site ❑ Refuse Vehicles Mof units) 11Dumpsters > 20 cu yd (#of units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care 11Acute Care ElSkilled Nursing ❑ Large Generator 11Small Generator ❑ Limited Hauler ❑ Transfer Station ElVeterinary Clinic 11Common Storage Facility ❑ 2 - 10 011-60 El> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46424 03 Blue Application Form CONTACT PERSON LAM A'Y1 Day Ph is(/°( -�(p Lw -=v Ph PROGRAM ELEMENT 4I t) FEE 1.o3� ❑ Surchar e F ❑Other FEE INSPECTORg /# 1153 PERMIT VALID -t a t0 ZZ ElFood Handler Ild Check # '710.3 AMOUNT PAID QD � ate INVOICE # /LLI Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE R CO D INFORMATION PINK 1/23M3 Program 3 Facility PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) LiHotel/Motel ------ Number of Units L.1Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee HousinplLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment L1UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site 11UIC Site ❑ Abandoned HW Site Elnon-NPUSEP Cleanup Site ElRWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ElPoultry Farm -------Maximum number of birds_ TATTOO. BODY PIERCING, ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) Body Art Facility -Single Use (4120) ElBody Art Facility -Sterilization (4121) ElBody Art Temp Event Co-ord (4130) ElBody Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper VehicleRegistration # License # Capacity Vehicle # 1:1Pumper Yard 11Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ElLandfill El Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site L1Waste Tire Facility ElCompost Facility ElProcess/Recycle Facility ElCIA Landfill Site ❑ Refuse Vehicles Mof units) 11Dumpsters > 20 cu yd (#of units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care 11Acute Care ElSkilled Nursing ❑ Large Generator 11Small Generator ❑ Limited Hauler ❑ Transfer Station ElVeterinary Clinic 11Common Storage Facility ❑ 2 - 10 011-60 El> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46424 03 Blue Application Form CONTACT PERSON LAM A'Y1 Day Ph is(/°( -�(p Lw -=v Ph PROGRAM ELEMENT 4I t) FEE 1.o3� ❑ Surchar e F ❑Other FEE INSPECTORg /# 1153 PERMIT VALID -t a t0 ZZ ElFood Handler Ild Check # '710.3 AMOUNT PAID QD � ate INVOICE # /LLI Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE R CO D INFORMATION PINK 1/23M3 03 Blue Application Form CONTACT PERSON LAM A'Y1 Day Ph is(/°( -�(p Lw -=v Ph PROGRAM ELEMENT 4I t) FEE 1.o3� ❑ Surchar e F ❑Other FEE INSPECTORg /# 1153 PERMIT VALID -t a t0 ZZ ElFood Handler Ild Check # '710.3 AMOUNT PAID QD � ate INVOICE # /LLI Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE R CO D INFORMATION PINK 1/23M3