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L!t OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID a(o Program Record ID Facility Address /cf3 v C w(./S E/Z /fi/C - 71)C-Ic 1� IL) C (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# u — ❑ Mobile Food Prep Unit--Make Vehicle Type Calor 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 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 UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel----Number of Units - El 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 ❑ 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) ❑ 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 Toilets----Number V'At45MENT SOLID WASTE PROGRAM (4400) [RgpID El Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Sitete ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑OMiLwindflft� El Refuse Vehicles (aof units) 11Dumpsters>20 cu yd(#of units) ❑ arm/ aJJnch Cleanup Site MEDICAL WASTE PROGRAM (4500) SAN JOAQUIN COUNTY ❑ aA Primary Care El Acute Care ❑ Skilled Nursing El Large Generator ❑ Small GelffHj Npuler El Transfer Station El Veterinary Clinic El Common Storage Facility ❑ 2-10 ❑ 11 - 0 >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 M Day Ph - -'i'1 Q Night Ph�q-11 I-Y1317 PROGRAM ELEMENT 1103 FEE ❑ surcharge FE /�7 �, 11 Other FEE INSPECTOR# � PERMITVALID J to ! 'll /0 Z/ ❑ Food Handler ❑ Ch k# AMOUN PAID Date INVOICE# Z❑ REVIEWED BY ACCOUNTING OFFICE Date 7$ 1123113 2-034 MASTERFILE RE ORD FO MATION PINK 1!2