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SAN JOAQUIN COUNTY IRVIRONMENTAL HEALTH DEPAIWiIENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proqram at Existing Facility ::2qew=Program and New Facil <br />Facility ID rAoDc,2,: $37 Program Record ID T K-03j-U(xo Z <br />Facility Address a(o55 G. i` rv-, Ay P,_ 1A Q- A , o64u ), gSZOS <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El 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 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 B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />COPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PER 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 />❑ 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 />11 Environmental Assessment 171UST-CAPSite El Local HW Cleanup Site [INPLISEP Cleanup Site El UIC Site <br />11 Abandoned HW Site . _ El Water Quality Remediation Site <br />Number of Pools/Spas at Fa <br />❑ Poultry Farm -------Maxi <br />Pool]Spa <br />❑ Natural Bathing Area <br />❑ Kennel <br />❑ Body Art PractitionerRe PECIALIZING IN UNDERGROUND <br />UTILITIES dy Art Facility -Single Use (4120) <br />11Body Art Facility-Steriliz OFFICE: 956-65000 <br />-5.00 dy Art -Temp Event Mobile Facility (4131) <br />2655 E. MINiR, SUITE A STATE LIE. #879357 <br />LIQUID WASTE PROGRAM (42 STOCKTON, Ck 95205• <br />El Pumper Vehicle Registrat - 649-2038 <br />i Vehicle # <br />GAN •- 9565-65007 Dts ----Number of Units <br />11 Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />El Landfill ❑ Transfer Station Ag/Cannery Waste Site ❑Sludge/Ash Site <br />Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />El 'Refuse Vehicles (� of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care El Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler <br />El 11 - 60 [1 > 60 generators <br />11 Transfer Station El Veterinary Clinic El Common Storage Facility El - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 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 .LI" A () -FEE ` <br />INSPECTOR # PERMIT VALID <br />PAID <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food. Handler_ -- <br />Date <br />INVOICE ## <br />❑ Check # AMOUNT <br />❑ Cash REVIEWED BY lit 41gls ACCOUNTING OFFICE Date <br />aa-oz-osa APR 2 4 2015 MHS ERFILE RECORD IN <br />FORMATION PINK <br />