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SAN JOAQUIN COUNTY �,VIRONME TAL HEALTH DEPARTVtNT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro ram at Existing Facility I ❑New EH Program and New Facility <br /> Facility ID D17 J /J l Pr ram Record ID <br /> Facility Address V IBD �S=ksm PVL gAof1 <br /> (Please check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM It 600) <br /> ❑ Restaurant: Seating Capacity_ Square Footag Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Pre aration ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/ eat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle T,vpe 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 _ 11Ice Plant 11 Produce Stand <br /> El Special Event--Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Numb of chemicals, <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program�3"Facility <br /> Hazardous Waste Generator(2200)-------> Tons Ge orated Per Year Sir-r�,L/ Gcna_is"ly-r <br /> ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ E (2233.2234, 2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST) (2800) umber of Yea <br /> ❑ Underground Storage Tank Program (LIST)(2300) Use STA and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution ---Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camig Application Form <br /> SITE MITIGATION(2900) UNDER ROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Lc Cal HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup 5ite ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility, ❑ Pool 6pa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-----Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM 100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSP i Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temi Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicleRegistration# Licens e it Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Print ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ NglCannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ rocess/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles I#of Unim) ❑ umpsters>20 cu yd(#c1unas) ❑ Farm/Ranch 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 ❑ Comn ion Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-0 -003 Blue Application Form <br /> --�- ,EMERGENCY NOTIFICATION R THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON 1Dt� U 4C' Day Ph !!T 4C S-1900 Night Ph -5ariUA-` <br /> PROGRAM ELEMENT 2 FEE x-,2 7 ❑ Surcharge FEES ❑ Other FEE <br /> INSPECTOR# 300 / PERMIT VALID 4� 1 / to 1!2-2-31 Z/ 4e ❑ Food Handler <br /> N ❑ Check# AMOUNT PAID Date INVOICE# -?--7YI, <br /> ❑ Cash REVIEWED BY h'1 - P//b6?-� AccouNTIjIGOFFICE Date 4i4'/ZS/y <br /> 48-02-034 <br /> 1/23/1.3 MASTERFILE RECORD INFORMATION PINK <br />