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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" t <br /> and Now Facility <br /> FacilityID G2771iL Program Record ID $y f 77 <br /> Facility Address 111"1 S LAKI,tTw Oki °I 520'�j <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: Yrs❑ 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 Typg Color <br /> Registration# License# �1 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 /> ❑ 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) ❑ PER 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 ❑ 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 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) PAYMENT <br /> ❑ Pumper Vehicle Registrationlit License# Capacity –@��` <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Nurtib2T"tit"t1Tif[s <br /> SOLID WASTE PROGRAM(4400) II <br /> IN �)() ' <br /> Landfill Transfer Station Ag/Cannery Waste Site I geQ Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility SAN 0A481kenWH>9lte <br /> ❑ Refuse Vehicles mof Units) ❑ Dumpsters>20 cu yd(#of Units) Et19IfNWMT& CCleanup Site <br /> MEDICAL WASTE PROGRAM(4500) HEALTH DEPARTME T <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12-10 011 -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 8 Night Ph /N ( <br /> PROGRAMELEMENT <br /> t'W FEE2 –1 — ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ��D' I PERMIT VALID S J2, Z( t0 �i 3� )v ❑ Food Handler <br /> 11Check# •VT�S"—AMOUNT PAID -4 23–T Date INVOICE#/ )— <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date lQ Z Z <br /> 4M2-034MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 * Z4 q / 3 / 2— <br />