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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID Fic:::0,2_77 67 -7 Program Record ID <br />Facility Address tIO Fl Rt"){4 ti 0 '31 ' <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 0 <br />Commissary 0 Dry storage only 0 with Food Preparation ElVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments ID Prepackaged Goods Only <br />El Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to D Ice Plant 0 Produce Stand <br />El Special Event---Dates of operation from to D CFO EADB <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals . <br />LI 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 /> <br />0 Jail or Exempt Institution ----Number of Units <br />Housing/Labor Camp Application Form <br />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 LI non-NPL/SEP Cleanup Site D RWQCB Cleanup Site D Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility F3 Pool 0 Spa 0 Out of Service Pool/Spa D Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />LI Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) D Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard D Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />El Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care D Acute Care 0 Skilled Nursing LI Large Generator LI <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />ErGENCY NWIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />Cl Hotel/Motel Number of Units <br />Employee Housing (2700) Use Employee <br />SITE MITIGATION (2900) <br />CONTACT PERSON Ntt Day Ph(g, ' Night Ph <br />LI Ag/Cannery Waste Site <br />DI Process/Recycle Facility <br />LI Dumpsters > 20 Cu yd ftl of Units) <br />Sludge/Ash Sipia <br />CIA Landfill <br />LI <br />b <br />Air <br />OYAii, <br />elti%, Farm/Ranch*A14; <br />Small Generator • Linga eayler <br />11 - 60 enerat260 <br />/14447.8 umico <br />pA a.447-,4upity <br />48-02-03 <br />1/23/13 <br />PROGRAM ELEMENT <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />ErCas Vl 5141 REVIEWED BY <br />(4( FEE <br />1 LQ Le's 21Dit -=-111-. in ccuLd +11%-- ectAyku _ <br />; 7-- <br />813123 <br />ACCOUNTING OFFICE <br />LI Surchar <br />to <br />Date <br />2 <br />0 Other FEE <br />E1 Food Handler <br />INVOICE # <br />Date g*3 11 MASTERFILE RECO D I FORMATION P NK