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r s <br /> _] <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Pro ram and Ne_w Facility <br /> Facility ID ?i5s� (p Pro ram Record ID P'ID S' ' LPj <br /> .f acility Address S �(o�mi�-e i 2 , i`V1AT1 CSA- 9s33G <br /> lease 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 /> ❑ Special Event---Dates of operation from to [] 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 /> ❑ 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 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 ❑ 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-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity D <br /> ❑ Pumper Yard 1:1 Package Treatment Plant El Chemical Toilets----Number of lin <br /> SOLID WASTE PROGRAM(4400) R <br /> 1:1Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slud / h iortl <br /> 1:1 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Cl d l ite <br /> ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd t#of Units) ❑ Farm/wR�lara ite <br /> MEDICAL WASTE PROGRAM(4500) SAENVJV1ROtAmeN T <br /> PARTMEN <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generat9Xi%4?fi ed 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 /> I fyejo Sa `+/ctiY EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> ONTACTPERSON . Day PhQkq)(O2qNight Ph(UA)(029- <br /> PROGRA <br /> M ELEMENT �� FEE ❑ Surc arge F E ❑ Other FEE <br /> �O.R# PERMIT VALID ® to ❑ Food Handier <br /> 5`� MOUNT PAID Date 1 INVOICE# Z <br /> REVIEWED BY ACCOUNTING OFFICE ate 141 <br /> 48-02-034 ;r AfASEERFILE RECORD INFORMATIONF PINK <br /> 1/23/13 <br />