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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existinq Facility ❑New EH Proaram and New Facility <br />II Facility ID yAj�02 /. r Program Record ID rR7)z l=15V 1 II <br />Facility Address \\0 N. k Urn S�oclt m, CA- ULOR <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 Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility —Dates of operation from <br />❑ Special Event ---Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ Color <br />Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to ❑ Ice Plant ❑ Produce Stand <br />to 11 CFO ❑A❑B <br />❑ 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 <br />❑ Hazardous Waste Generator (2200)--------> -Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <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 <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 ❑ Sludge/ ite <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑CIA L <br />11Refuse Vehicles i#of Units) ElDumpsters > 20 cu yd i# of Unitsl L1Farm/R ite <br />MEDICAL WASTE PROGRAM (4500) A,,,. �V <br />11 Primary Care ❑Acute Care ❑Skilled Nursing El Large Generator ❑Small Genera�or ❑ L�Mitp�l ler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60dF ;�a,r0 gentiors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form <br />CONTACT <br />PROGRAM E <br />INSPECTOR # <br />❑ Check # <br />❑ Cash �� <br />48-02-034 <br />1/23/13 <br />:NT M IJ I FEE <br />Z PERMIT VAL <br />AMOUNT PAID <br />REVIEWED BY' %,((III 11 <br />'Day Ph <br />fC'y 0 S <br />to _ <br />Date <br />ACCOUNTING OFFICE <br />: I� 2-1`64114 <br />Night PhI Z01 <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # 7 <br />Date �P <br />