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SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTN T <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility Chew EH Program and New Facility <br />Facility ID F-400.2 26 <br /> <br />Program Record ID sikSerg-7 <br /> <br />Facility Address <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 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />IZIJVIobile Food Vehicle --Make F;r,e-:e Vehicle Type -57teP V'?// Color 141/-71-e- <br />Registration # 31 31/143,786'6-2C-Xicense # 73S----c;C3' 3--c2 Sticker # /9 5-9 <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0CF0 0A0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CU PA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units oc <br />SOLID WASTE PROGRAM (4400) 01 <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site %Sit <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility dfill <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of Units) /Ratiitt lev4 Site <br />MEDICAL WASTE PROGRAM (4500) e‘cS) st‘OL,)te'((,0 <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small GeneratoNli ter <br />*nerators <br />0 Kennel <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EME,R2ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON girGinAM ffoctsacfee-- Day Ph s—acY-- 70)(- Night Ph <br />504 <br />PROGRAM ELEMENT \ \C)g S- FEE 0 Surchar F 0 Other FEE <br />INSPECTOR # PERMIT VALID k2A -2.1 1.0 to k2- 0 Food Handler <br />Check # (Ae‘ri \-- AMOUNT PAID A) 20.3 --7• C:51-) Date INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />kkex -L D.39 <br />Date /7,-,-27?g- <br />MASTERFILE ECO D INFORMATION PINK 48-02-034 <br />1/23/13