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SAN JOAQUIN COUNTY•VIRONMENTAL HEALTH DEPAIIIENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility []New EH Program and New Facility Facillt ID Program Record ID ' �' x Facility Address (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ 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 License# Sticker# Registration# Color El Mobile Food Prep Unit--Make Vehicle Type Registration# License# Sticker# to [I Ice Plant El Produce Stand El Temporary Food Facility--Dates of operation from El CFO [I A 13 B 11Special Event---Dates of operation from to 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 ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER(2231) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Jail or Exempt Institution----Number of Units ❑ Hotel/Motel------Number of Units Employee Housing (2700) Use Emplovee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) El Environmental Assessment ElUST-CAPSite 11 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site El UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) ❑ Pool spa ❑ out of Service Pool/Spa 13 Natural Bathing Area Number of Pools/Spas at Facility_ VECTOR CONTROL PROGRAM (4000) ❑ Kennel ❑ Poultry Farm-------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM(4200) Capacity VehlCle# ❑ Pumper Vehicle Registration# License# Y ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash Site El Landfill ❑ Transfer Station 11 AglCannery Waste Site ❑ Waste Tire Facility ❑ Compost Facility El 11 CIA Landfill Site Process/Recycle Facility 13 Farm/Ranch Cleanup Site El Refuse Vehicles (#of units) ElDumpsters> 20 cu yd (#of units) MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph EINSPECTOR M ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE # PERMITVALID tO ❑ Food HandlerAMOUNT PAIDDate INVOICE# REVIEWED BY ACCOUNTING OFFICEDate (J Co MASTERFILE RECORD INFORMATION PINK 1/23/13