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SAN JOAQUIN COUI TY (IRONMENTAL HEALTH DEPAP ENT <br /> MAST RFILE RECORD INFORMATION FORM <br /> New EH Program at Existing liacility ❑New EH Program and New Facility <br /> Facnit-Y-1D Program Record ID <br /> Facility Address ® i 11J • L' S -' 7 <br /> (Please check the appropriate de cription and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacit Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage my ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footag ❑ with 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 --Da es of operation from to El Ice Plant <br /> El Special Event Dates of operat on from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ rade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Busines Plan (1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> 15'Hazardous Waste Generator( 200)----------> Tons Generated Per Year e 5— <br /> El <br /> ❑ Tiered Permitting Facility----- -> ❑ CA(2232) ❑ CE (2233, 2234, 2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank F cility(AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank P gram (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Uni ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Emp o ee Housing/Labor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment UST-CAP Site 13 Local HW Cleanup Site ElNPL/SEP Cleanup Site ElUIC 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(400 ) <br /> ❑ Poultry Farm-------Maximum nu ber of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMAN NT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (411 ) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization 121) ❑ 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 (4 4(00) <br /> ❑ Landfill ❑ Tran fer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Com ost 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 Ca ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterina Clinic El Common Storage Facility 132- 10 1311 -60 El >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM 600) Use PWS EHD 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 '227,16 FEE Z V V ❑ Surchar a FEE ❑ Other FEE <br /> INSPECTOR# 2(Z PER IT VALID �( to 2 11Food Handler <br /> ElCheck# AMOU T PAI Date INVOICE# <br /> 13 Cash REVIEWED BY <br /> (/ (� ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 8/21/12 <br />