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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />LMASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br />I Facility ID -T-A0C)2-GSg2 Program Record ID f KD5`f{o%2�-) I <br />Facility Address 2lo Ul. (ia4 k-- <51 <br />(Please check the appropriate description and si <br />pecfy sJ number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />Square Footage <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑ Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑ Mobile Food Vehicle -Make <br />Vehicle Type <br />Registration # <br />License #_ <br />❑ Mobile Food Prep Unit-- Make <br />Vehicle Type _ <br />Registration # <br />License # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event --Dates of operation from to <br />R�cF AFD <br />MAY 20 <br />S. IV coq ?021 <br />ENV/ QUIN <br />HEALTHo PMENOU/VTI. <br />aR1-1 F6v <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />to ❑,,,tttIce Plant 11 Produce Stand <br />(>;JCFO tYJA❑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 <br />❑ Hazardous Waste Generator (2200)--- ------ >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -> OCA(2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ 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 ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP 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 Farts ----Maximum number of birds <br />❑ 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 # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle #, <br />❑ Chemical Toilets —Number of Units <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 (#of Units) ❑ Dumpsters > 20 cu yd I# 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 Ph Night Ph <br />PROGRAM ELEMENT /(,OF FE , On. 13 Surcharge FE 11 Other FEE <br />INSPECTOR# .3,'��0 / PERMIT VALID � 2 t0 S 3/ ;Z- ❑ Food Handler <br />❑ Check# — AMOUNT PAID J77Z On Date .5/2Z/2-/ INVOICE# .' Jaz-777 <br />❑ Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />Date S/Zs/ <br />133MASTERFILE RECORD INFORMATION PINK <br />1/23/3 (-Ol--f'ri2G.)— <br />