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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facli t New EH Pro am and New Facilit <br />Facilit ID j Program Record ID <br />Facility Address 110 N EL ORADO <br />(Please check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />O Restaurant: Sealing Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />0 Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />O Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # <br />0 Mobile Food Prep Unit-- Make Vehicle Type <br />Sticker # <br />Color <br />Registration #License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />ID Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />ID Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />O Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />O 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 LUC Site <br />Abandoned HW Site 0 non-NPLISEP 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 />0 Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 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 />0 Pumper VehicieRegistration 4 License 4 Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />0 Kennel <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />0 Refuse Vehicles mot units) 0 Dumpsters > 20 Cu yd (Not units) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />--cartrIi-(MERGENCY <br />NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON -e-r- tAe4eidotA Day P11 21,X1 • Q-21 'OS12. Night Ph 144 •541•SS i 1 <br />PROGRAM ELEMENT 1681 FEE $237 0 Other FEE INSPECTOR # 9828 PERMIT VALJ <br />0 Surclrge F <br />0 Food Hand r 0 Check # V 1/2 4--- AMOUNT PAID — <br />to I I <br />INVOICE # Date ) i (.7 ) --c2 oR 0 Cash REVIEWED BY ACCOUNTING OFFICE Date 1 30 :1;62,-"3, 46-02-034 <br />103/13 <br />Note: Okay to issue permit (SR0087423) <br />MASTERFILE R CORD INFORMATION PINK <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />4r ib