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i SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPAR*NT MASTERFILE RECORD INFORMATION FORM El hew EHRProgram at Existing Facility ❑New EH Program and New Facility Facility ID F g�`tProgram Record ID Facility Address L Lb'4& (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes I-] No ❑ ❑ Commissary El Dry storage only El with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only El Multiple Departments 13 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: CalARP Program ❑ Program 1 Facility ❑ Program 2 Fac it ❑ Program 3 Facili y Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2234, 2235, 2237) ❑ 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 Exempt Institution----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment El UST-CAP Site 1:1 Local HW Cleanup Site 13NPL/SEP Cleanup Site [3 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 El Pool El Spa ❑ out of Service Pool/Spa El Natural Bathing Area 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) Vehicle# ❑ Pumper Vehicle Registration# License# Capacity ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site El Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site g ❑ Waste Tire Facility ❑ compost Facility 11Process/Recycle Facility ❑ CIA Landfill Site El Refuse Vehicles (#of Units) ElDumpsters> 20 cu yd (#or Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care 11 Acute Care ❑ Skilled Nursing El Large Generator El Small Generator ❑ Limited Hauler ❑ Transfer Station [IVeterinary Clinic ElCommon Storage Facility ❑ 2-10 El 11 -60 El >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 rPROGRAmELEMEN,T Z� 7— FEE ��` ❑ Surcharg FEE ❑ Other FEE# T Z k PERMIT VALID t0 02 ❑ Food.Handler AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY fJ ACCOUNTING OFFICE Date �f MASTERFILE RE—COR16 INFOF6AATION PINK 48-02-034 1123/13