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SAN. JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proaram at Existing Facilitv ❑New EH Proaram and New Facilitv <br />I Facility ID -1-,1 0291. // C Program Record ID 1 ICUS`t (1(n5 II <br />Facility Address V ( M U1 <br />(Please check the appropriate description and specify size, nurhber of unit,- <br />FOOD <br />nit:FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />❑ Mobile Food Vehicle -Make Vehicle Type <br />Registration # License # <br />and pertinent information.) <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ Color <br />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------> OCA(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 ❑ 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 # <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 Loa0fill Site <br />❑ Refuse Vehicles (#of units) 11Dumpsters> 20 cu yd (#of units) 13Farm/ISite <br />MEDICAL WASTE PROGRAM (4500) RF [f"`��II�� <br />❑ Primary Care 11 Acute Care ❑ Skilled Nursing EI Large Generator L1 Small Generator l Lii f &r <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 -10 ❑ 11 -60&># jggU,eer tors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form SANJIA-. ��UU <br />CONTACT <br />PROGRAM[ <br />INSPEC R# 7M <br />❑/n1 3/J 1 y o <br />❑ Cash 1'17REVIEWED <br />48-02-034 <br />1/23/13 <br />r�p FEE <br />PERMIT VAL <br />AMOUNT PAID <br />Day Ph <br />❑ Su <br />2o2f to <br />Date <br />ACCOUNTING OFFICE <br />/ Night Ph •"ur <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # 6" <br />- Date ML <br />MASTERFILE RECORD INFORMATION <br />