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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID Program Record ID Facility Address 14-5 1 In) . 1 n we 11 �)V f-'. Tr c �4 1 '15 3-Ro (Please check the appropriate description and specify size, number of units and p inent 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 Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ic Plant ElProduce Stand ❑ Special Event---Dates of operation from to Ej CFO ❑ 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 Facility ❑ Program 3 Facility ❑ 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 USTA 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 Housinq/Labor Camp Application Form SITE 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-NPUSEP 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) ❑ Poultry Farm------Maximum number of birds ❑ Kennel 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 f Toilets—Number PEW SOLID WASTE PROGRAM (4400) ❑ Landfill 11 (�Transfer Station ❑ Ag/Cannery Waste Site Zf��vsR ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 9`�` �f�� ❑ Refuse Vehicles(#of units) ElDumpsters>20 cu yd(#of Units) m nch Cleanup Site MEDICAL WASTE PROGRAM(4500) SAN JOAQUIN COUNTY ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small GeneotditR � hyuler El Transfer Station ❑ Veterinary Clinic 11 Common Storage Facility ❑ 2-10 ❑ 11F Wdffl, > generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERG NCY NOTIFICATION FOR THIS FA LITY AND/OR PROGRAM CONTACT PERSON ll © ( c C Day P 0-5)30Night Ph PROGRAM ELEMENT I (Q R FEE �, ) ) ❑ Surcharge F ❑ Other FEE INSPECTOR# L,I T)h Lc r e S PERMIT VALII�D,,<< � �/% to I /3`�7/2-Z, ' ElFood Handler El Check# AMOUNT PAID / Date LC I VOICE# IJ/Cash REVIEWED BY ACCOUNTING OFFICE U Date 1 1 - (o - ( q 48-b2-034 I ASTERFILE RECORD INFORMATION PINK 1/23/13