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SAN*JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 Kennel <br />(4400) <br />CI Transfer Station El Ag/Cannery Waste Site CI Sludge/Ash Site <br />CI Compost Facility 0 Process/Recycle Facility CI CIA Landf le <br />Units) El Dumpsters > 20 cu yd (# of Units) El Farm/Ran <br />El <br />ReCen <br />Limited Ha.diregb <br />1=1 akik r*4 <br />'1A1 JO"; EiVviR Cou <br /> <br />QUOv A, HpA , 0AnifE ,_ —ILitinkr ik Aq.Fiwriv _r <br />(6 <br />Surcha ge F O-other FEE <br />to 2-<c 0 Food Flzailer <br />Small Generator <br />0 11 - 60 <br />INvoicE# <br />Date <br />New EH Program at Sxisting-FaGility r-fr 19000 ONIew EH Pro ra and New Facility <br />Facility ID Program Record ID tj CIU PA) <br />Facility Address 1,C-1, C_,-c;\Atc_..wk c Cic/b ciP <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # <br />CI Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />FOOD PROGRAM (1600) <br /> <br />0 Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />o Mobile Food Vehicle --Make Vehicle Type <br />License # <br />Vehicle Type <br />Food Handlers Course required: YES a No 0 <br />0Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site 0 Abandoned HW Site CI non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration # License # Capacity Vehicle # 0 Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM <br />CI Landfill <br />CI Waste Tire Facility <br />CI Refuse Vehicles (# of <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care CI Skilled Nursing CI Large Generator 0 <br />CI Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT FEE <br />INSPECTOR # PERMIT VALID <br />0 Check # AMOUNT PAID <br />Date <br />0 Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />MASTERFILE RECOR <br />APa400 5 14- <br />INFORMATION PINK <br />33.4J2, <br />48-02-034 <br />1/23/13