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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT S L —_ MAS'TERF.ILE RECORD iNFORMATIUN FORM LV \U New EH Program at Existing Facility _ ❑New EH Program and New Facilit Facility ID Program Record ID y ro Facility AddressCA (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 Q.Retell Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only I P.Mobllp.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 t.Lti+ to L-! ❑ Ice Plant❑ Produce Stand �� ❑ Special Event---Dates of operation from_ to ❑ CFO ❑ A ❑ B AIRY PROGRAM (2000) ❑ Grade A Dalry ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit Cl Hazardous Materials Business Plan (1900) Number of chemicals: CalARP:Program ❑ Program 1 Facility D Program 2 Facility ❑ Program 3 Facility El 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 Foran SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIQNAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) El Poultry Farm-------Maximum number of birds ❑ Kennel TATT00 BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 0 B.ody.Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) 9=Body 1.Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) ;LIQUID WASTE PROGRAM(4200) �.Pumper..VehicleRegistration# License# Capacity Vehicle# ❑ Pumper_Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM(4400) Landfill ❑ Transfer Station D Ag/Cannery Waste Site ❑ Sludge/Asti Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site El Refuse Vehicles(#or units) ❑ Dumpsters> 20 cu yd (#or 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 ❑ 2- 10 D 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form p EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM �(� A P R$ON t � ' (2,M)lt Day Ph C � 8 ' 3x55 Night Ph ONT -- O PROGRAM ELEMENT 1 iD 2— FEE ��1►v ElSurchar e FE D Other FEE INSPECTOR# PERMIT VALID 157 to D ZC> ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cast) REVIEWED BY _ ACCOUNTING OFFICE �� Date 67-5' 7�j 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13