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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT , <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ZNeW EH Program and New Facil' <br /> Facili ID Program Record ID <br /> Facility Address Q </ Celf ClS3 b <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 /> ❑ 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 �FO 11A�B <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 /> El11pw�.q <br /> CalARP Program Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility '7 .oI p° <br /> ❑ Hazardous Waste Generator(2200)-->-Tons Generated Per Year ft •V <br /> ElTiered Permitting Facility—> 11CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ P%PLH W, Q <br /> El Aboveground Storage Tank Facility(AST) (2800) Number of ASTs v 20 <br /> ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B forms %JO ?920 <br /> ❑ Other CUPA Program y FMyRQU/N <br /> HOUSING PROGRAM(2400) �/0F�Nrgt 7'Y <br /> ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution—Number of Units FVr <br /> Employee Housing (2700) Use Employee Housina/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 ❑ 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(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicleRegistration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles wof Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site . <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ 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 Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day P '7 Night Ph ©G1 7 1.10 (OZ 3 <br /> PROGRAM ELEMENT 1 (0 0 FEE 31 0 v ❑ Surcharge FEE 11 Other FEE <br /> INSPECTOR# / PERMIT VALID, t0 11 Food Handler <br /> E3 check# AMOUNT PAI Date ,- 2i� INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 4 1 I MAS7ERFILE RECORD INFORMATION PINK <br /> 1/23/13/23/13 / <br />