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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> <br />MASTERFILE RECORD INFORMATION FORM <br />EH Program and New Facility <br />Facility Address 607 e. AviqqcsLIA 51r. <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 0 <br />CI Commissary CI Dry storage only El with Food Preparation CIVending Machines Number of Units <br />Retail Market----Square footage El w/Meat Market only CI 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 />CI Temporary Food Facility --Dates of operation from to Cl Ice Plant El Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) <br />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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site El U IC Site <br />CI Abandoned HW Site CI non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool CI Spa D Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp EvNtirittfthity (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity RECEIVED <br />Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />P ZUZ3 SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station El Ag/Cannery Waste Site IA e. wry I <br />Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility ber <br />eSh <br />El Dumpsters > 20 cu yd (// of Units) 1;4&,fflitigPOINIStqfPP Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care I=1 Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 ID 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON c\i,,,,c,,A <br />ME <br />, Day PbCic\-- (,:i -j --5 (PC, Night Ph '7__CrA -- 6 - —-112._ <br />CI New EH Program at Existing Facilit <br />Facility ID Flt19/7 ,2q11/ Program Record ID <br />CI Kennel <br />Refuse Vehicles (# of Unus) <br />PROGRAM ELEMENT 10 7-4 FEE 55:N/0 Sur <br />./ <br />F E <br />PERMIT VALID4072,q...3_, 2-- INSPECTOR # W2-Z • <br />El Check # V AMOUNT PAID * Date 2v 2. <br />Cash REVIEWED ACCOUNTING OFFICE <br />48-02-034 <br />Other FEE <br />Food Han die <br />I OICE # <br />Date <br />MASTERFILE CORD NFORMATION PINK <br />1/23/13