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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Facility ID Program Record ID Facility Address O �� et S (Please check the appropriate description and specify size, number of unit; FOOD PROGRAM (1600) El Restaurant: Seating Capacity. Square Footage El Commissary ❑ Dry storage only El with Food Preparation El Retail Market ----Square footage ❑ w/Meat Market only El Mobile Food Vehicle --Make Vehicle Type Registration # License #_ El Mobile Food Prep Unit-- Make Vehicle Type . Registration # License # _ ❑ Temporary Food Facility --Dates of operation from to ElSpecial Event ---Dates of operation from to DAIRY PROGRAM (2000) El Grade A Dairy ❑ Grade B Dairy and New Facil z /_5_ and pertinent information.) q Food Handlers Course reuired: YEs ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments El Prepackaged Goods Only _ Color Sticker # Color _ Sticker # ElIce Plant ElProduce Stand ❑CFO ❑A❑B ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA J 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 (223 1) ❑ 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 Emplovee 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg k ❑Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use k4 120) ❑ 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 # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Trans fer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles (# of Units) Capacity Vehicle # Pumper Yard ❑ Chemical Toilets ----Number of Units El Ag/Cannery Waste Site ❑ Process/Recycle Facility ❑ Dumpsters > 20 cu yd (# of Units) El Sludge/Ash Site ❑ CIA Landfill Site ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care 1:1 Acute Care Skill Nursing El Large Generator 11 Sm 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 Niqht Ph PROGRAM ELE NT FEE El Surcharge FEE ❑Other FEE � INSPECTOR # e� Z. PERMIT VALID to El Food YO -VL -V J4 MASTERFILE RECORD INFORMATION PINK 1/23/13 ❑ Check # ❑ Cash AMOUNT PAID REVIEWED BY Date ACCOUNTING OFFICE Handler INVOICE # Date J YO -VL -V J4 MASTERFILE RECORD INFORMATION PINK 1/23/13