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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />n <br />Facility ID �ii(ia� <br />Facility Address <br />r� <br />❑New EH <br />Record ID <br />RECD VED <br />(Please check the appropriate description and specify size, number of units and pertinent information.) �JOAgUINCO <br />FOOD PROGRAM (1600) NEACTy ppONn'1ENTUNn' <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course reaulred: Y�s°E�T�N7` <br />❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑Multiple Departments. ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑Ice Plant ❑Produce Stand <br />❑ Special Event ---Dates of operation from to ❑CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑Grade 6 Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑Program 1 Facility ❑Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑PBR HHW (2236) <br />❑ Hotel/Motel------Number of Units ❑Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camn Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑UST -CAP Site ❑Local HW Cleanup Site ❑NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned <br />HW Site <br />❑non-NPLISEP <br />Day Ph <br />Cleanup Site <br />❑ RWQCB Cleanup Site <br />❑Water Quality Remediation Site <br />RECREATIONAL <br />HEALTH <br />PROGRAM <br />(3600) <br />� Z <br />t0 _ <br />Number of Pools/Spas at Facility _ ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑Kennel <br />TATTOO 800Y PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑Sludge/Ash Site <br />❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site <br />❑ Refuse Vehicles I#or units) ❑ Dumpsters > 20 cu yd (#of units) ❑ FarmlRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />(4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />PERSON � L � <br />'� <br />Day Ph <br />PROGRAM <br />ELEMENT�iId FEE <br />� mt� <br />❑ SUi <br />INSPECTOR # � PERMIT VALID <br />� Z <br />t0 _ <br />Check # <br />AMOUNT PAID <br />.�D <br />Date <br />1❑! <br />JKJ Cash <br />REVIEWED BY <br />ACCOUNTING <br />OFFICE <br />7/23/73 <br />Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE# 3�� <br />Date �/7/Z,J- <br />