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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID/-��]. <br />Facility Address <br />(Please check the appropriate description and specify size num)3er of unit <br />,F OD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market—Square footage <br />❑ Mobile Food Vehicle –Make ❑ '^r/Meat Market only <br />Registration # Vehicle Type <br />El Mobile Food Prep Unit– Make License #_ <br />Vehicle Type <br />Registration # _ <br />EJ Temporary Food Facilityoperation <br />#_ <br />–Dates of o eration from <br />❑ Special Event—Dates of Operation from <br />to <br />ryCCF;V�6 <br />SEP 2 8 2021 <br />Food Handlers Course repuired� YEsNo ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />to ❑ Ice Plant ❑ Produce <br />❑CFO ❑A❑B <br />DAIRY PROGRAM (2000) <br />ff Grade A Dairy ❑ Grade B Dai <br />CUPp ry El Milk Dispenser -Number of Containers in Multi -Head Unit <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 —> ElCA (2232) CICE (2233, 2234, 2235, 2237) 1:1PBR (2231) 11PBR HHW (2236)- <br />ElAboveground 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 <br />Employee Housing (2700) Use Emolol bor Camp Application lExempt Institution —Number of Units <br />t n Form <br />Houshlq La <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 <br />VECTOR CONTROL PROGRAM (4000) El Natural Bathing Area <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO BODYPIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel <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 VehicleRegistration # License # Capacity <br />❑ Pumper Yard❑ Package Treatment Plant 1:1 Chemical Toilets —Number of Units <br />hicl# <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/AshSite <br />Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility CIA Landfill Sit <br />ElWaste <br />❑ Refuse Vehicles Oor units) ❑ Dumpsters > 20 cu yd O of Units) <br />MEDICAL 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 1111-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON <br />PROGRAM ELEMENT_ '� �Q I –t FEE <br />INSPECTOR #\(ICY-NA(�ERMIT VAL <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWED BY <br />46-02-034 <br />1/23/13 <br />Day Ph <br />1]i <br />❑ Surcharge FEE ❑ Other FEE <br />i �21 to 2 .b' ZZ ❑ Food 11�E <br />Date <br />ACCOUNTING OFFICE <br />INVOICE <br />Date <br />