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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Pro ram at Existing Facility ZNew EH Program and New Facility <br /> <br />Facility ID <br /> <br />Program Record ID Preo5q-S 417 <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />CI Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care CI Skilled <br />CI Transfer Station CI Veterinary Clinic <br />PUBLIC WATER SYSTEM <br />CONTACT PERSON <br />PROGRAM ELEWF NT <br />INSPECTOR # <br />El Check # <br />g(C)‹h vimq REVIEWED BY <br /> PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />DEP 7k EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />MEN HEAL. <br />SI udpkip.m <br />CIA "3411111g. NT <br />Far ty Site <br />Small Generatol9EPLiln3e1Wy.yler <br />CI 11 -BAN ] > 60 gentiators <br />EA, QU/N <br />09 -t/S3- zI22j - Day Ph Night Ph ARTMENT <br />FEE <br />PERMIT VALID <br />AMOUNT PAID <br />Nursing CI Large Generator 1:1 <br />CI Common Storage Facility CI 2- 10 <br />CI Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />CI Dumpsters > 20 cu yd of units) <br />Food Handler <br />INVOICE # 3 52T3 <br />Other FEE <br />Date 6? 323 <br />CI <br />El <br />El <br />El Surchar e F <br />to <br />Date <br />ACCOUNTING OFFICE <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> <br />('Mobile Food Vehicle --Make Vehicle Type <br />CI Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # (‘7i (i) <br />Sticker # <br />Color <br />Color <br /> <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <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 />CI Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment CI UST-CAP Site CI Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa El Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # <br />CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORDINFORMATION PINK <br />Capacity Vehicle #