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SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID FitV 0D(p20.7 Pro ram Record ID Facility Address 10 5D N 5{- (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 Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make VeH'itle 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 El Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility Hazardous Waste Generator(2200)-----> Tons Generated Per Year___�� 1 &212 Tiered Permitting Facility------> ❑ CA(2232) ❑ CE (2233,2234,2235,2237) ❑ PBR(2231) I❑ 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) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing (2700) Use F lee Housing/Labor Camp Application FormSITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area, VECTOR CONTROL PROGRAM(4000) , Cl Kennel ElPoultry 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) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash elAsh Site 1:1 Landfill ❑ Transfer Station EIAg/Cannery Waste Site g ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility- _ ❑ CIA Landfill Site ty - ❑ Refuse Vehicles (#of units) ❑ Dumpsters> 20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site :MEDICAL WASTE PROGRAM(4500) 11 Primary Care El Acute Care ❑ Skilled Nursing 1:1 Large Generator 11 Small Generator 11 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 PROGRAM ELEMENT/D FEE �r"1, 10 U El Surcharge Fee - 11 Other FEE INSPECTOR# ,� PERMITVALID 1 /1 ) )L4 to 12-151 11 ,+ ❑ Food.Handler ❑ Check# AMOUNT rPnI0 Date INVOICE# 1:1L�Cash REVIEWED BY Col'- I ACCOUNTING OFFICE Date MASTERFILE RECORD INFORMATION PINK 48-02-034