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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existina Facilitv 'dew EH Proaram and New Facilitv Facilik ID Facility Record ID M6F(21O (Please check the appropriate description and specify stze, 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 At License # Sticker # ❑ Temporary Food Facility -Dates of operation from to❑ Ic )ant El Produce Stand El Special Event --Dates of operation from to CFO 1Z 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 EVProgram 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 Cama 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -----Maximum number of birds ❑ Spa ❑ Out of Service Pool/Spa TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard ❑ Natural Bathing Area ❑ 05�(�ft' AIIIENIT� Body Art Facility-Si-VI,i s Body Art -Temp EveAMbjl® m2ty (4131) License # Capacity ❑ Package Treatment Plant ❑ Chemical Toilets----Number�OUNTY-- SOLID WASTE PROGRAM (4400) �AKr MENT ❑ 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 (# 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 NJDTIFICATION FOR THIS FACILITY. D/ R 959.29U CONTACT PERSON Day Ph If fight Ph P PROGRAM ELEMENT FEE 1U ❑ Su ge FE 11 Other FEE INSPECTOR# PERMIT VALID 'y 7h Z t0 -7 D 1- ❑ Food Handler ❑ Check # VL5 r,,— AMOUNT PAID DateIINN�VOICE # - Lam