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SAN •JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />at <br />II Facility ID NACn 27 f C-�D Program Record ID i KOS47L IZ II <br />Facility Address '2L,i2F-.�4;j,,,t ,S — <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 <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type <br />Color <br />Registration # License # 54 <br />2 019 L 1 Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility -Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ 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) ❑ PER (223 1) ❑ 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 -El 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-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-TerrpAvfM Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (# of units) <br />Capacity RECpey=r% <br />❑ Chemical Toilets--NumANaf 4ln6 <br />s <br />2022 <br />❑ Ag/Cannery Waste Site <br />❑ Process/Recycle Facility <br />❑ Dumpsters > 20 cu yd (#of units) <br />SAN IdAVUMOGUN8TSite <br />HE E� Mei I fSits <br />++arm�Ilanch 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 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON J %i Gi. - T - <br />DayPh,�7n•�i' Chrrl� Night Ph kLS— <br />PROGRAM ELEMENT I (� Z2 Lj FEE I ❑ Surcharg <br />e FE 1:1 Other FEE <br />INSPECTOR# PERMIT VALID L t0 I2-/2Z❑Food Han/dyer <br />q Check # AMOUNT PAID — Date 2-- INVOICE <br />Cash REVIEWED BY ACCOUNTING OFFI Date <br />1/23/13 <br />