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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New <br />ID <br />Record ID <br />and New <br />Facility Address `�rrnl[tyl <br />\�� <br />'��21�Q27� <br />SGIt-lU ��nCl <br />(Please check the appropriate description <br />and <br />specify size, number of units and <br />pertinent information.) <br />FOOD PROGRAM (1600) <br />Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑Multiple Departments ❑Prepackaged Goods Only <br />RECE QED <br />MAY %�,� <br />❑ <br />Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: YEs ❑�"Nb ❑ <br />❑ <br />Commissary ❑Dry storage only <br />❑with Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑Multiple Departments ❑Prepackaged Goods Only <br />❑ <br />Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />Vehicle # <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Mobile Food Prep Unit --Make <br />Vehicle Type <br />Color <br />❑CIA Landfill Site <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Temporary Food Facility --Dates of operation from <br />to ❑Ice Plant ❑Produce Stand <br />❑ <br />Special Event ---Dates of operation <br />from to <br />❑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 />❑ 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 Employee Housins/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑UST -CAP Site ❑Local HW Cleanup Site ❑NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑non-NPUSEP 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 <br />❑Kennel <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />,� Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body <br />Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body <br />Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # License # Capacity <br />Vehicle # <br />❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets <br />----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site <br />❑Sludge/Ash Site <br />❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility <br />❑CIA Landfill Site <br />❑ Refuse Vehicles (>«of units) ❑ Dumpsters > 211 cu yd to of units) <br />❑Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ❑ 2 - 10 <br />❑ 11 - fi0 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITYANDIOR PROGRAM <br />/� I� <br />CONTACT PERSONS \[A�� \ � Day Ph $Orj—ILD —1 I n,�nNight <br />Ph <br />PROGRAM ELEMENT 4 I i� FEE � ($ 2 ❑ Surcharg/e FEE ❑Other FEE <br />INSPEc7oR# X831 PERMIT VALID S to (aft'% ❑Food Handler <br />❑ Check #AMOUNT PAI Date � �Z INVOICE # 3 �S <br />❑Cash REVIEWED BY ACCOUNTING OFFICE Date 5�,3 <br />48-02-034 '` ���� � �.�7 MASTERFILE RECORD FORMATION PINK <br />1/23/13 ✓ir➢�J (/ <br />