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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> MASTERFILE RECORD INFORMATION F16IRM <br /> ❑ New EH Program at Existing Facility New EH Program and New Facilit <br /> Facility IDn':) o2 �Z Program Record ID <br /> Facility Address 2 ( I/J 15�5o(p <br /> (Please check the appropriate description and specify size, number of units d nd pertinent information.) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating CapacitySquare 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 /> El Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License#ZCi 2 Sticker# <br /> T <br /> 11 Temporary Food Facility–Dates of operation from to 11 Ice Plant 11 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 /> ❑ CaIARP 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 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-NPLISEP 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 UnitsI <br /> SOLID WASTE PROGRAM (4400) F GUA-D <br /> ❑ Landfill 1:1 Transfer Station ❑ Ag/CanneryWaste Site ❑ Slu <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Side <br /> 11 ��Refuse Vehicles w of units) 11ElDumpsters>20 cu yd to of units) Farm/ h a�� Ite <br /> MEDICAL WASTE PROGRAM (4500) COUNTY <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small GeneratoI50�y 114 <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 H�.A@f&0 to, NT <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGR M <br /> CONTACT PERSON a. 2 Day Ph 'r fight Ph <br /> PROGRAM ELEMENTt 4 _ FEE �v ❑ Surchar a FE ❑ Other FEE <br /> INSPE <br /> C <br /> TOR# PERMIT VALID t0 C tl o Z ❑ Food Handler <br /> ❑ 66E�t#�L'S1 AMOUNT PAID '— Date 1' /,0 Z INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 4 1, 2- <br /> 4842-034 MASTERFILE RECORD INFORMATION PINK <br /> 1123113 y} r 2-Ig(a <br /> 'g(a G 't_ I, <br />