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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility IRNew EH Program and New Facility <br />Facility ID <br />f fjQ7,_t <br />%ra <br />Program <br />Record ID r jQA3 %{"j$_j j� <br />Facility <br />Address <br />445 W Beverly Place , <br />Tracy, CA, <br />95376 <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 <br />❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP 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) ❑ PER (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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number fm 1 10 s 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) 19 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) <br />❑ Landfill ❑Transfer Station ElAg/Cannery Waste Site ❑Sludge �/j <br />y�� <br />El Waste Tire Facility El Compost Facility 11Process/Recycle Facility 1:1 CIA Lan Si a- "G.IN <br />❑ Refuse Vehicles (#& Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ FarmIRV& OIISaW� Site <br />MEDICAL WASTE PROGRAM (4500) S ��G,:; <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ® Small Generator 01l d*llprY <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 �AT}}p ors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form "AIT <br />CONTACT <br />Day Ph <br />PROGRAM ELEMENT r�/ZO FEE 't ❑SI <br />INSPECTOR#�83L PERMIT VALID P.S Z IO <br />Handler <br />,❑/ Check # �/r AMOUNTPAID 2 Date <br />IJ CO$h V�FM REVIEWED BY ACCOUNTING OFFICE <br />❑Other FEE <br />❑ Food <br />NV # <br />to <br />Date g l <br />48-01-U34 ^ N <br />f� <br />ICE <br />MASTERFILE RECORD INFORMATION PINK <br />7/23/13_,t/v'r1{_ <br />