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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 0New EH Program and New Facility <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 <br />Commissary Cl Dry storage only 0 with Food Preparation <br />Registration # <br />0 w/Meat Market only <br />Vehicle Type <br />License # <br />retail Market----Square footage <br />Mobile Food Vehicle --Make <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />El Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program CI Program 1 Facility El 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) El 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 CI NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool <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) El Mechanical DSPS Notification (4115) C7 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />h Site <br />Irte <br />Atteb <br />0 Large Generator DI Small Generator igitV89ep Hauler <br />0 Common Storage Facility 0 2 - 10 0 11 - j00.>Q1.6:04v3,ceotaufteit3:1,rs <br />htettril?Oiviti <br />DEPARIV,.rAt <br />MPisir <br />Facility ID F-Ana:-/s3 Program Record 1E, ttD5-1/-cg <br />Facility Address \-7 I) S: '&,(\[3'(\ - t CkViN') 01 -2.6i..e <br />Food Handlers Course required: YES 0 No 0 <br />LIVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />El Spa 0 Out of Service Pool/Spa El Natural Bathing Area <br />0 Kennel <br />SOLID WASTE PROGRAM (4400) <br />Landfill <br />0 Waste Tire Facility <br />Transfer Station <br />Compost Facility <br />Refuse Vehicles (4 of units) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care <br />Transfer Station DI Veterinary Clinic <br />CI Skilled Nursing <br />El Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />El Dumpsters > 20 cu yd (f( of Units) <br />Sludge/ <br />CIA La <br />CI Farm/ <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM EMERGENC <br />V\T T;f 1AOU CONTACT PERSON Day Ph Night Ph <br />PROGRAM E <br />INSPECTOR # <br />11;1(he k <br />W6111- REVIEWED BY <br />48-0 -034 <br /> 123/13 <br />=4 7 <br />0 Surchar <br />Date <br />ACCOUNTING OFFICE <br />efe insp-editoK.. One hu,{12) 8t2cmtp ,ERF:LER"" <br />FEE <br />PERMIT VALID <br />ORMATION PINK <br />0 Other FEE <br />CI Food Handler <br />INVOICE # 3g36 <br />Date