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Facility ID r/ co 2 S Program Record ID PP115.4"3M- <br />CI Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />0 Surchar e F <br />to 3 3 <br />Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />El Food Handler <br />2-- NvoicE # ‘,.5-O <br />Date 3 ?572-:3 <br />MASTERFILE R COR INFORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility Olq-ew EH Program and New Facility <br />Facility Address K ?-__0Se Lkict k I LA/A_J\ <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 0 No 0 <br />CI Commissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage El w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />CI 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 CI Ice Plant 0 Produce Stand <br />CI Special Event---Dates of operation from to CICF0-0A0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />ID Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI 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 />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site CI U IC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 12 Pool CI Spa <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Vehicle MAR 1 3 2023 <br />CI Chemical Toilets ----Number of Units <br />El Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br /> 0 CIA Lan I <br />At <br />ite <br />CI Sludge/ <br />CI Farm/Ranch Clrepa <br />SAN JOAQUIN COUNTY <br />ONMENTAL <br />En PuApRsTitMeENT <br />Small Generator 0 Limited Hauler <br />0 11 - 60 > 60 generators <br />0 Body Art Facility-Single UsePAYMENT <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event MobiliatENED <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # <br />CI Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (4 of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator El <br />El Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFXATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON ( 4-4-VJ Day Phc i it- 5- 11 Light Ph <br />Capacity <br />PROGRAM ELEMENT i LO(A FEE <br />IN ECTOR # (rt PERMIT VALID <br />Check # 1 1::/ '..) AMOUNT PAID <br />Cash REVIEWED BY <br />48-02-034 <br />1/23/13