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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility Alew EH Program and New Facility Facility ID F Program Record ID UZ Facility Address N Sc-� moa � o C1 r2-° Z (Please check the appropriate description and specify size, number of units and 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 ❑ Mull iple 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- umber of Containers in Multi-Head Unit_ CUPA ,H 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------> OCA(2232) ❑ CE(2233,2234, 2235,2 37) ❑ PBR(2231) ❑ PBR 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) ❑ Hotel/Motel----Number of Units ❑ Jail or Exerr pt Institution----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CO TROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Clear up Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of I ervice Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) i ❑ 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 (41 0) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# apacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic 1 Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Si e ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Fac lity ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cup yd (#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Appucati n Form EMERGENCY NOTIFICATION FOR THIS FACILITY AN /OR PROGRAM CONTACT PERSON �y Day Ph Night Ph PROGRAM ELEMENT yyl! L.O FEE S S ❑ Surcharge F E ❑ Other FEE INSPECTOR# L99 R-Z PERMIT VALID to 1 ❑ Food Handler ❑ Check# AMOUNT PAID ate INVOICE# EI Cash REVIEWED BY �O A2 ACCOUNTING FICE Date 48-02-034 MASTERFILE RECCIRDIWnRMATION PINK 1/23/13