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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL <br />MASTERFILE RECORD IN <br />�1 <br />DEPARTMENT <br />p Facility ID - -A00. /,7S/ Program Record ID 11 <br />Facility Address �fl I �1 1 10 Kty �M-M/7 '%c�P20-� <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: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market --Square footage ❑ 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 <br />to <br />DAIRY PROGRAM (2000) <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />Color <br />Sticker # <br />_ Color _ <br />Sticker # _ <br />❑ Ice Plant <br />❑CFO ❑A❑B <br />Produce Stand <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) ❑ 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 Housina/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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />❑ Spa ❑ Out 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) ❑ 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 Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludgf Nr <br />ElWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 1:1CIA <br />ElRefuse Vehicles (#o(Units) ❑ Dumpsters> 20 cu yd (#otUnits) ❑Farm/Ran Site <br />MEDICAL WASTE PROGRAM (4500) nn ''nn..��.. <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Genera or PLL �tLd4Mer <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 -10 ❑ 11 - 6� Eh 'n O"Wtors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-0 -003 Blue Application Form HEALTH Dep "ENTAL <br />p E ERG N ATION OR THIS FACILITY AND/O PROGRAM Y"HENT y <br />CONTACT PERSON I Day Ph �`� Night F -Sl © 5 U r��7o ©/ <br />PROGRAM EJ,E�E T I IVC-' FEET <br />INSPECTOR# [�� PERMITVAL <br />❑ Check # AMOUNT' PAID <br />11 Cash REVIEWED BY w V l� l/ <br />48-02-034 n <br />1/23113 I ' <br />U,UV El S, <br />2=-02-1 to <br />tf Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE #. 3e5� <br />Date g <br />