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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existina Facilitv ❑New EH Program and New Facility Facility ID m Record ID Facility Address (�1 Z . l I eve`oa ,z�l., Sok hif , C?5 Z2 r (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 El No El lCommissary El Dry storage only El with Food Preparation ❑Vending Machines Number of Units 1:1 Retail Market ----Square footage Elw/Meat Market only El Multiple Departments El Prepackaged Goods Only El Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # El Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # El Temporary Food Facility --Dates of operation from to El Ice Plant El Produce Stand El Special Event ---Dates of operation from to 1:1 CFO El 11B DAIRY PROGRAM (2000) El Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA f Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program 11 Program 1 Facility El Program 2 Facility El Program 3 Facility El Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year El Tiered Permitting Facility -------> El CA (2232) 11 CE (2233, 2234, 2235, 2237) El PBR (223 1) El PBR HHW (2236) 1:1 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs El Underground Storage Tank Program (UST) (2300) Use UST A and B forms El Other CUPA Program HOUSING PROGRAM (2400) ElHotel/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) El Environmental Assessment ElUST-CAP Site 1:1 Local HW Cleanup Site ElNPL/SEP Cleanup Site ElUIC Site 1:1 Abandoned HW Site El non-NPL/SEP Cleanup Site ElRWQCB Cleanup Site El Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) ❑❑ Pool/Spa ❑Natural Bathing Area Number of Pools/Spas at Facility Pool VECTOR CONTROL PROGRAM (4000) 11 Poultry Farm -------Maximum number of birds_ Spa ❑Out of Service ❑ 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) El Body Art Temp Event Co-ord (4130) El Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) El Pumper Vehicle Registration # License # 1:1 Pumper Yard ❑ Package Treatment Plant 11 SOLID WASTE PROGRAM (4400) El Landfill El Trans Station El Waste Tire Facility ❑ Compost Facility El Refuse Vehicles 0 of units) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units Waste Site ❑ Process/Recycle Facility ❑ Dumpsters > 20 cu yd (# of Units) Ag/Cannery El SludgelAsh Site ❑ CIA Landfill Site ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ElPrimary Care El Acute Care ❑ Skill ed Nursing El Large Generator ❑Small Generator El 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 Day Ph Night Ph PROGRAM ELEMENT FEE INSPECTOR # PERMIT VALID ,LL F.] Check # AMOUNT PAID El Cash REVIEWED BY El Surcharge FEE to Date ACCOUNTING OFFICE El Other FEE 11 Food Handler INVOICE # e Dat 48-02-034 IVINJICRI'ILC f(CI.VRV IIVrVRIVIl111VIV r1IVn 1/23/13