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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ❑ New EH Program and New Facility <br /> Facility ID Program Record ID F906V12DD <br /> Facility Address 3422 WC-3 Hammon W r.Q 1 o <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 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 /> El Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CaIARP 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 Empiovee Housing/Labor Camp Application Farm <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 VehICIGRegistration # 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 ❑ Slu a/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CI ite <br /> ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ rrRestc up Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Goner mited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 1519 LJ mq/ nerators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form H FNVRDU/NCO <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMTHpEp FNTTNf1' <br /> CONTACT PERSON Q/*l Day Ph 1 fight Ph 16Np <br /> PROGRAM ELEMENT 4110 FEE 6R ❑ Surch rge EE ❑ Other FEE <br /> INSPECTOR # PERMIT VALID to 691vtv El Food Handler �yy' <br /> ❑ Check # AMOUNT PAID J Date INVOICE # U JlJ <br /> ❑ CashWgj) REVIEWED BY ACCOUNTING OFFICE4ptX Date <br /> 48-02-034 �„ ✓_ _r' - VI FORMATION PINK <br /> 1 /23113 L��7 Vjq <br />