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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility r(lev../Ell Program and New Facility <br />Facility ID Pair1.2 "21/10 r63 Program Record ID ?g-0 k I <br />0 Sludge/Ash Site <br />LI CIA Landfill Site <br /> LI FarmiSAnch Cleanup Site <br />Small Generatoitte <br />LI 11 - 60 0 <br />lem <br />Nlier <br />ors <br />Facility Address a4 E. j,siorTh Sk S40cY-40r1 CA q50(. <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />LI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No El <br />Commissary 0 Dry storage only 0 with Food Preparation LI Vending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only El Multiple Departments 0 Prepackaged Goods Only <br />LI Mobile Food Vehicle --Make Vehicle Type Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals <br />CalARP Program El Program 1 Facility 0 Program 2 Facility El 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 />El Hotel/Motel 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 />I: Abandoned HW Site LI non-NPL/SEP Cleanup Site D RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard El <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station <br />Compost Facility <br />El Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care LI Acute Care LI Skilled El <br />Transfer Station El Veterinary Clinic Common Storage Facility El 2- 10 <br />CONTACT PERSON <br />Date <br />Registration # License # <br />El Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to D Ice Plant D Produce Stand <br />LI Special Event---Dates of operation from to Ed CFO VAEl B <br />El Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />LI Jail or Exempt Institution ----Number of Units <br />CI Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />License # Capacity Vehicle # <br />El Landfill <br />Waste Tire Facility <br />Package Treatment Plant <br />Nursing Large Generator 0 <br />Ag/Cannery Waste Site <br />LI Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />0 Chemical Toilets ----Number of Units <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form (v/A y 1 6 <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 43,4 <br />PROGRAM ELEMENT 16)04R FEE <br />INSPECTOR # Chil-9S,29 PERMIT VALID <br />LI Check # <br />REVIEWED BY <br />AMOUNT PAID <br />cx V15F 48-(A-034 <br />1/23/13 <br />NJo,4Qu LUIS MectirAck Day Ph tlinkN Agar _(..024) 30 a-2011 Night Ph ENV/Ro /N CO(' <br />S. , <br />,AENY. • <br />I • <br />ACCOUNTING OFFICE <br />to l )( <br />Surch rgetEE <br />Date J 2-5 <br />2023 <br />LI 11"//1 At Other FEE--r-ARTLENr <br />0 Food Handler <br />INvoicE fi I 3 <br />)/t7 <br />STERFILE RECORD IN ORMATION PINK