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1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTSEpia80(e-o L <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program andNew Facility <br /> Facility ID FA 00, __Program Record iD 7 A�U� SYi <br /> Facility Address 2 b(ems. <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 ❑ No ❑ <br /> i' ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> I �etall Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> D Mobile Food Vehicle--Make Vehicle Type Color <br /> ' Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Slicker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> El Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> is <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers In Multi-Head Unit___ <br /> CUPA <br /> [].Hazardous Materials Business Plan(1900) Number of chemicals: <br /> C] CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> C] Hazardous Waste Generator(2200)---- ---> Tons Generated Perl'ear P � <br /> Tlered Permitting Facllity------> LICA(2232) ❑ CE (2233,2234, 2235,2237) ❑ PER(2231) ❑ as <br /> ❑.Aboveground Storage Tank Facility(AST) (2800) Number of ASTs �f!/E® <br /> ❑ Underground Storage Tank Program (UST) (2300) Use USIA and B forms �`A� <br /> 11OtherCUPA Program I'' 0 2019 <br /> HOUSING PROGRAM(2400) SAIV jgAQUIN <br /> ElHotel/Motet -----Number of Units El Jail or Exempt Institution ----Nur%rFi914jj C OIJA17" <br /> Employee.Housing(2700).Use Employee Housing/Labor Camp Application Form EALTH 1) PAR-r <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) MENT <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLiSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon 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 /> 1:1Poultry Farm-----•-MaxllilUm number of birds ❑ Kennel <br /> ,TATTOO 80DY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> 13 Body Art Facillty-Sterilization(4121) ElBody Art Temp Event Co-Ord(4130) El Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehlcleRegistration# License# Capacity Vehicle# <br /> El Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑:L81I dfill ❑ Transfer Station ❑ AgiCannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles o of units) ❑ Dumpsters>20 cu yd til or Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> TransferStation ❑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 Fort <br /> E RGENCX NOTIFICATION FOR THIs FACILITY ANDIOR PRO RAM <br /> CONTACT PERSON Wv t U Day Ph-Afi Night Ph <br /> PROGRAM ELEMEN/T� 15 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# v n^ PERMIT VALID S i to ❑ Food Handler <br /> ❑ Checic# .AMOUNT PAII INVOICE# 3 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date S <br /> 48-02-034 n MASTERFILE RECOR13 INFORMATION PINK <br /> 1/23113C�r�g21 q <br />