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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ew EH Proaram and New Facility <br />Facility ID <br />Proqram Record ID <br />Facility Address 2. g'7 S" Gam.' L <br />(Please check the appropriate description and specify size, number of units and <br />FOOD PROGRAM (1600) <br />4 S"2 3 ;� <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 TColor <br />ype <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from to _ <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />_ <br />Sticker # <br />❑ Ice Plant ❑ <br />❑CFO ❑A❑B <br />Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA _ <br />�azardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />ElElHazardous Waste Generator (2200)-- ........ >-Tons Generated Per Year. <br />El Tiered Permitting Facility -------> El CA (2232) El CE (2233, 2234, 2235, 2237) <br />El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />Program 3 Facility <br />❑ PBR (2231) ❑PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel ------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 ❑ 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 <br />Spa O <br />VECTOR CONTROL PROGRAM (4000) <br />ElPoultry Farm -------Maximum number of birds <br />❑ ❑ut of Service Pool/Spa ❑Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑BW Art Facility -Single Use (4120) <br />ElBody Art Facility -Sterilization (4121) ElBody Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />El <br />Pumper Vehicle Registration # <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />11 Pumper Yard <br />❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />11Landfill El Trans Station ElAg/Cannery Waste Site ❑Sludge/Ash Site <br />13Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility ElCIA Landfill Site <br />❑ Refuse Vehicles I# of Units) ElDumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />ElPrimary Care ElAcute Care ElSkilled Nursing ElLarge Generator ❑ Small Generator ElLimited Hauler <br />1:1Transfer 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 Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM EL�E T `f FEE El Surcharge FEE El Other FEE <br />INSPECTOR # � (9, L -HERMIT VALID t0 El Food <br />Handler <br />ElCheck # AMOUNT PAID Date INVOICE # <br />11 <br />Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />