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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH <br />II Facilitv ID .P -LI Proaram Record ID 4M' S-4.7S1/zt. h 11 <br />Facility Address Iao? IKgr;aer'y (a ire 45336 1-c,?hfe'/ L/� <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 Tvoe Color <br />Registration # License #_ <br />❑ Mobile Food Prep Unit— Make Vehicle Type <br />Registration # License # _ <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Sticker # <br />Color <br />Sticker # <br />to , 11IIcee lant El Produce Stand <br />IJ CFO L7A ❑ B <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-----> ❑ 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 Emoloyee Housina/Labor Camp Anolication 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 ❑ 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 Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ----Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfi,!! <br />11 Refuse Vehicles (# of Units) 13Dumpsters > 20 cu yd (# of Units) eye <br />rr tt <br />MEDICAL WASTE PROGRAM (4500)�1'/�` <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Li(/I%leduler D <br />11 Transfer Station El Veterinary Clinic 11 Common Storage Facility 112 - 10 El 11 - 60 11>>`��.g n af? <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />PROGRAM ELEMENT II DU )i FEE <br />Day PI <br />❑ SI <br />INSPECTOR# X /%X <br />PERMITVALID t0 <br />❑�Check# <br />AMOUNT PAID Date <br />Ud/C<-034 <br />_ <br />REVIEWED BY <br />(�'��' ACCOUNTING OFFICE <br />48-01123 <br />1123!13 <br />AAlu <br />Ph ( <br />❑ Other FEE <br />❑ Food Her <br />INVOICE # <br />Date 7 2 <br />