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SAN JOAQUIN COUNTY IMIRONIVIENTAL HEALTH DEPARIONT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID 7A <br /> LZ (o Program Record ID <br /> cility Address - ► 1 -1 lD 25� \.6kYI22 <br /> lease 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 ❑ CFO ❑ A ❑ 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 /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR(2231) ❑ 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 ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housinq/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 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(4400) PAY <br /> ME <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgftoCVVED <br /> 11Waste Tire Facility ElCompost Facility ElProcess/Recycle Facility 11CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/Rj&h QI*67419ite <br /> MEDICAL WASTE PROGRAM (4500) I uNTY <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ��� <br /> 1:1Transfer Station 1:1Veterinary Clinic E3Common Storage Facility ❑ 2- 10 011 -60 ttt +++ OERAftXM <br /> SNT <br /> WATER SYSTE <br /> gBL'C <br /> NTACTPERSONM P`ROGRAM (4E6M0E0R)GUEsNeCPY WNOSTEIFHICDAT4IO6N-0F2O-R00T3HIBS lFuAeCAILpIpTlYicAaNtiDo/nORFoPrRmO <br /> GRAM <br /> ght Ph <br /> PROGRAM ELEMENT W20 FEE_ r �� ❑ Surcha/pga FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID ( t0 2 ie2 ❑ Food Handler <br /> ❑ Check# ' AMOUNT PAID ,2?2 Date INVOICE# `17 <br /> 1:1 CV1>0` REVIEWED BY ACCOUNTING OFFICE Date 7 3 <br /> 48-02-034 MASTERFILE RECORD NFORMATION PINK <br /> 1/23/13 <br />