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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility :New EH Program and New Facility <br />+- Facility Address <br />Facility ID <br />Le ) A-e_/-(er 54- L04); (s, <br />Program Record ID Pk05-Lf L-C7 <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 0 Dry storage only 0 with Food Preparation <br />opetail Market----Square footage 0 w/Meat Market only <br /> <br />g Mobile Food Vehicle --Make Vehicle Type <br /> <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br /> 0 CFO 0 A 0 B <br />5-2E'n <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <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 <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGNCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Lz s Day Ph 7-2-7 S-a-S-A-"iNight Ph <br />48- -034 <br />INSPECTOR # 33 <br /> 16 3s- -I PROGRAM ELEMENT FEE L 0 Surch rge FEE 0 Other FEE <br />113:1Zheck # AMOUNT PAID Date 1 2- 2-3 INVOICE # 370S7q <br />1/23/13 pbyeof--.)(, ek,q3it:1-i_s(61144EFILE RE ORD INFORMATION PINK <br />C V014 REVIEWED BY G_ F. ACCOUNTING OFFICE gOle.b/' ZIA), Date <br />PERMIT VALID ( 2.2423 <br /> <br />to 0 Food Handler <br />/ .23 <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />Body Art Facility-Single Use (4120) <br />Body Art-Temp Event Mobile Facility (4131) <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters >20 cu yd (# of Units) <br />GenerafilAtqlited er <br />0 1 1 - 6 ilizt.A <br />s <br />W) <br />DEPAR maw. <br />JCi st <br />Sludg <br />CIA L <br />Farm <br />s /WENT <br />inch Clea tfIaCkite <br />2 Rt7