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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at <br />Fact <br />❑New EH Proaram and New <br />Record ID <br />Facility Address_ 6 tj M(4jyj a4iod, W -A!- C4 q q3o <br />(Please check the appropriate description and specify size, number of units <br />and pertinent information.) <br />FOOD <br />PROGRAM (1600) <br />Generated Per Year <br />❑ <br />❑ <br />Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <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 />Registration # <br />License # <br />Sticker # <br />❑ <br />Mobile Food Prep Unit -- Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sucker # <br />❑ <br />Temporary Food Facility --Dates of <br />operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ <br />Special Event ---Dates of operation from <br />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) ------- <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 />TA 00 BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Body Alt 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 Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) p.� F <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge lAfts p <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Lang Site � <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑Fars/Ra cd fi Site <br />MEDICAL WASTE PROGRAM (4500) gNJOA !vG% <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generatdl � ITV r <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 -60 1� <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-0&003 Blue Application Form 'HENT <br />FMFRaFNeV NnTIF1r.ATInN FnR THTC FA r:II.ITY ANn/nR PRnriR AM <br />CONTACT <br />PROGRAM ELEMENT. <br />INSPECTOR Dr <br /># <br />❑,2heck # - <br />Cash <br />48-02-034 <br />1/23/73 <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED <br />BY <br />ay P' <br />' <br />� ❑ SI <br />t0 <br />Date <br />ACCOUNTING OFFICE <br />Night Ph ((_C <br />❑ Other FEE <br />_ ❑Food Handler <br />INVOICE # <br />Date 2�j ; <br />MASTERFILE RECORD INF <br />--->-Tons <br />Generated Per Year <br />❑ <br />Tiered Permitting <br />Facility -------> <br />❑ <br />CA (2232) <br />❑ 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 />TA 00 BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Body Alt 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 Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) p.� F <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge lAfts p <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Lang Site � <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑Fars/Ra cd fi Site <br />MEDICAL WASTE PROGRAM (4500) gNJOA !vG% <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generatdl � ITV r <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 -60 1� <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-0&003 Blue Application Form 'HENT <br />FMFRaFNeV NnTIF1r.ATInN FnR THTC FA r:II.ITY ANn/nR PRnriR AM <br />CONTACT <br />PROGRAM ELEMENT. <br />INSPECTOR Dr <br /># <br />❑,2heck # - <br />Cash <br />48-02-034 <br />1/23/73 <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED <br />BY <br />ay P' <br />' <br />� ❑ SI <br />t0 <br />Date <br />ACCOUNTING OFFICE <br />Night Ph ((_C <br />❑ Other FEE <br />_ ❑Food Handler <br />INVOICE # <br />Date 2�j ; <br />MASTERFILE RECORD INF <br />