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r <br /> 'SAN JOAQUIN COUNTY ENVTKONMENTAL HEALTH DEPARTM1 f7 <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility KNew EH Program and New Fa ility <br /> Facilit IDD.23D&? Pro ram Record ID Plis .3 �� 5r{D 3t'-7 <br /> Facility Address ` X220 I y?� <br /> (Please check the appropriate description and specify size, number of units an ertinent infor ion.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES ❑ No ❑ <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 VeHi61e 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 B Dairy/ ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ <br /> CUPA n <br /> I�J Hazardous Materials Business Plan(1900) Number of chemicals: L <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> Hazardous Waste Generator(2200)-------> Tons Generated Per Year 4S'kl^ <br /> EITiered Permitting Facility----> ElCA(2232) [1CE (2233,2234, 2235,2237) ❑ PBR(2231) ❑ 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 CU PA 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 Camp 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 HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <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 BODY 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 ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (#of Units) ❑ Dumpsters>20 cu yd (#of units) ❑ 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 ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR FIR GRAM <br /> CONTACT PERSON t h 7 f Day Ph 70{-I61 b Night Ph <br /> PROGRAM EL/FME T }'�7�'7-O FEE OW5 — rc arge FEE ❑ Other FEE <br /> INSPECTOR# V�srn�Lc PERMIT VALID to ❑ Food.Handler- <br /> El <br /> andler <br /> ❑ Check# AMOUNT PAID Date INVOICE# �U4�3� <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 31 I <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br />