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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 0-New EH Program and New Facility <br />Facility ID FAOC).27 07 <br />Program Record ID <br />DORA 00 S 1, #6 , TOOk TM, <br />specify size, number of units and pertinent information.) <br />Squ are Footage <br />0 with <br />Mobile Food Vehicle --Make <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <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) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />Facility Address S'0311 N F L <br />(Please check the appropriate description and <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Food Preparation <br />0 w/Meat Market only <br /> Vehicle Type <br />Food Handlers Course required: YES q., No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />CI Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing <br />Transfer Station 0 Veterinary Clinic <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />License # <br />0 Package Treatment Plant <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (t( of units) <br />0 Large Generator 0 <br />0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON;\P TH/ r tv v fvcic, Day Ph Z6.,' /, tr2 /ft; v Night Ph <br />0 Surcharge FEE 0 Other FEE <br />to 10 513)12 0 Food Handler <br />Date c312c51 2 3 INvoicE # 70 <br />133/Ca II (3 Pt REVIEWED BY ACCOUNTING OFFICEMOY. dip Date <br />48-02-034 <br />1/23/13 l(D/R6kH <br />MASTERFILE RECORD INFORMATION PINK <br />PROGRAM ELEMENT FEE <br />Sludge/Ash Site <br />CIA Landfill p <br /> o Farm/Ranc <br />Small Generator 0 Li dFiEtevto <br />0 11 - 60 ps4 > •I e,e5itm23 <br />N 0,1 <br />Afti/ QU/A/ C HEAL , ROAtm 0(iN„_ <br />IHDEP /‘/7./IL r 4F4,0t„Air <br />INSPECTOR # <br />I X <br />PERMIT VALID <br />Check # AMOUNT PAID