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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Prooram at Existina Facilitv []New EH Proaram and New Facility Facility ID Y-ACrDL//'fI Prooram Record ID iKUS�f 7/.X k- I Facility S2� (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 USTA 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 Housina/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 TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ 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 EvepA"ftciNW (4131) LIQUID WASTE PROGRAM (4200) CICY'D- ❑ Pumper Vehicle Registration # License # Capacity e G ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of�mi4a SOLID WASTE PROGRAM (4400) �R ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site IMMUOAC1'l9gil't TY ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle FacilityCa [�LRLdMGffI✓i x 11 Refuse Vehicles (#of units) ElDumpsters > 20 cu yd (#of Units) �+jEAA�T1�/R99Rim•FjWffiP 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 FO THIs FACILITY AND/OR PROGRAM y� �/ CONTACT PERSON`I u(`le� V f � wHh ZZ- light Ph W (•"IZL•�b�2 PROGRAM ELEMENT Ib } b FEE f) ❑ Surcharge FEE ❑ Other FEE INSPECTOR# / L ��d PERMITVALID 27 Z t0 31 Z ❑ Food Handler ❑ Check # 1.-L- AMOUNT PAID Date Z Z Z INVOICE # 3 S ❑ Cash REVIEWEDBY ACCOUNTING OFFICE Date S Zv 4!23/-334 CX11'{' Z� 7 Q V I I MASTERFILE RECO INFORMATION PINK