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SAN JOAQUIN COUNTYVIRONMENTAL HEALTH DEPAENT <br /> MASTERFIL ECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID Z / Pro ram Record jr /� G <br /> Facility Address 6 01 <br /> 'Y� tys� <br /> (Please check the appropriate description ands specify size, nu ber of units and pert' enta[ion)// // <br /> P z cKlo`) `jf—Zp <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity_ Square Footage <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Food Handlers Course required is ❑ No ❑ <br /> ❑ Retail Market----Square footage p ❑Vending Machines Number of Units <br /> ❑ w/Meat Market only ❑ Multiple Departments El Prepackaged Goods Only <br /> ❑ Mobile Food ----SqVehicle re ake foot <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# �— <br /> Registration# Vehicle Type Color <br /> ❑ Temporary Food Facility--Dates of operation from License# Sticker# <br /> El Special Event---Dates of operation from to to El ice Plant 1:1 Produce Stand <br /> El CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dai <br /> CUPA ry El Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Czardous Materials Business Plan (1900) Number of chemicals: <br /> IARP Program ❑ Program 1 Facility ❑ Program 2 Facilit <br /> ❑ Hazardous Waste Generator 2200 ----------> Y E3 Program 3 Facility <br /> ( ) Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ 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 <br /> Employee Housing (2700) Use EmployeeHousing/Labor Camp Appli❑cat'ol n Form <br /> l or empt Institution ----Number of Units <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number Of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# <br /> ❑ Pumper Yard Capacity Vehicle# <br /> SOLID WASTE PROGRAM (4400) <br /> P ❑ Package Treatment Plant ElChemical Toilets------Number of Units <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> El Waste Tire Facility 13 Compost Facility1:1 Sludge/Ash Site <br /> ❑ Process/Recycle Facility El CIA Landfill Site <br /> ❑ Refuse Vehicles(#or Units) ❑ Dumpsters>20 cudof Units)_ <br /> Y (# Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> MER E Y NOTIFICATION FOR THIS FACILITY AND PROGRAM <br /> CONTACT PERSON .e e D <br /> Night Ph <br /> PROGRAM ELE`MENT 19 1 � FEE Z 0 IS 7/OR <br /> INSPECTOR# �A L Z Other FEE� PERMITVALIDt0 ❑ Food Handler❑ Check# AMOUNT PAID !"'� , t i �,j Dat@❑ Cash INVOICE# - l`� r>' 'lREVIEWED BY ACCOUNTING OFFICE ;. Date <br /> 48-02-034 <br /> 1/23/13 MASTERFILE RECORD INFORMATION PINK <br />