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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERIFILE RECORD INFORMATION FO <br />Pr - <br />O• <br />New EH Program at Existing Facility New EH Program and New Fac <br />Facility ID FA�� __ Program Record ID Tib5�3��� <br />Facility Address M01 chilbot cit,eirac 1 o q5?)04 L: <br />(Please check the appropriate description and specify size, number of units and pertinent inforrnafion.) <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 Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ <br />Produce <br />ElSpecial Event ---Dates of operation from to El CFO ElA ElB <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ElGrade B Dairy <br />❑ Niilk Dispenser -Number of Containers in Multi -Head Unit <br />Stand <br />COPA <br />ElHazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ElProgram 1 Facility 11Program 2 Facility ElProgram 3 Facility <br />Hazardous Waste Generator (2200)----------> Tons Generated Per Year <br />ElTiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) El PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />ElUnderground Storage Tank Program (UST) (2300) Use UST A and B forms <br />ElOther CUPA Program <br />HOUSING PROGRAM ( <br />2400) <br />❑ Hotel/Motel ------Number Of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use EmploVee 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 El non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ElWater Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ElPool ElSpa 1:1Out of Service Pool/Spa ElNatural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (41 15) ❑ Body Art Facility -Single Use (4120) <br />ElBody Art Facility -Sterilization (4121) ElBody Art Temp Event Co-ord (4130) ElBody Art-Ternp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Pumper Yard <br />❑ Chemical Toilets -----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill El Trans Station ElAg/Cannery Waste Site ❑Sludge/Ash Site <br />ElWaste Tire Facility ❑ Compost Facility ❑ ProcesS/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ElDumpsters > 20 cu yd (# of Units) ElFarm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />1:1Primary Care ElAcute Care ElSkilled Nursing ❑ Large Generator ❑ Small Generator ElLimited Hauler <br />ElTransfer Station ElVeterinary Clinic ElCommon Storage Facility El2 - 10 El11 - 60 El> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fom7 <br />SO <br />N <br />PROGRAM ELEMEnev I <br />INSPECTOR # ��` <br />El Check <br /># <br />❑ Cash <br />48-02-034 <br />1123113 <br />FEE <br />CONTACT PER <br />Day Ph k�i-U?5 J <br />O��" (U4�'1-Night Ph <br />❑ Surcharge FEE ❑Other FEE <br />PERMIT VALID to El <br />AMOUNT PAIDDate INVOICE # <br />REVIEWED BY ACCOUNTING OFFICE <br />Food Handler <br />(,%J Date '�l/17 /1 <br />NtASTERFILE RECORD INFORMATION PINr< <br />