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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 Facilit ID Program Record ID Facility Address 1 Q r, - f e� cj: , /O`kfc,. 'i ; / S- ( 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 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 : _ ❑ CaIARP 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 ❑ 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 of Units SOLID WASTE PROGRAM (4400 ) ❑ Landfill ❑ Transfer Station ❑ Ag /Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd I# of 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 ❑ 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 p Day Ph Night Ph PROGRAM ELEMENT ! 2 FEE ❑ Surcharge FEE El Other FEE (_. INSPECTOR # o z �'' PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1 /23/13