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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facili []New EH Program and Now Facili <br /> FacilityID 2 Program Record ID T <br /> FacilityAddress Z401 i I rc c!, ( RS 37(o <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 ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# 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 /> 0 Special Event—Dates of operation from 10/2221 to 10/22/2022 0 CFO 0 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 HousindLabor Cama 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(36011) tt <br /> Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ N�VMaiNP,rea <br /> VECTOR CONTROL PROGRAM(4000) r2ECEIVE® <br /> 13 Poultry Farm—Maximum number of birds ❑ enneI <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) OCT 2 7 2021 <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art FacilitySingleUse(411 2Q�„NN <br /> ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Ev L4131) <br /> LIQUID WASTE PROGRAM(4200) HgLTH DEPARTMENT <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 ❑ AglCannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcessiRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#el Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 011 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Font <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Mary Hood Day Ph 608-446-3733 Night Ph 608-046-3733 <br /> PROGRAM ELEMENJI FEE ❑ Surcharge FE — 11 Other FEE <br /> INSPECTOR 7 PERMIT VALID 7 ZO 1/I t0 J 2�❑ Food Handler <br /> ,PkCheck# 2-;'4- AMOLVJT PAID — Date Z I INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02034 MASTERFILE RECORD INFORMATION PINK <br /> 1/2Y13 <br />