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to <br />Date <br />ACCOUNTING OFFICE <br />t„ <br />Ceiv,v <br />Fea n At) <br />Program Record ID '---Z!)57-1-cgq413 84 I V ,in 2024 <br />on CA s3 -L coNr„COuiv <br />and pertinent information) <br />Food Handlers Course required: YEs jgr No CI <br /> <br />CI Vending Machines Number of Units <br />CI Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID FA 00 2s-06 -{ <br />(Please check the appropriate description and specify size, nurAer of units <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />CI Commissary CI Dry storage only CI with Food Preparation <br />Retail Market----Square footage El w/Meat Market only <br />CI Mobile Food Vehicle --Make Vehicle Type <br />License # <br />ID Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />CI Special Event---Dates of operation from to %CFO A CI B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />ID Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) E:1 PBR (2231) CI 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 />CI Environmental Assessment CI UST-CAP Site El Local HW Cleanup Site El NPL/SEP Cleanup Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site El Water Quality Remediation <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility D Pool CI Spa CI Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />1:1 Poultry Farm Maximum number of birds 1:1 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />ID 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 # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (tt of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 121 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 <br />PfNiew EH Program and New Facility <br />Facility Address `-/ '2:I Van IP kfri Wau <br />Registration # <br />UIC Site <br />Site <br />CI Natural Bathing Area <br />El Ag/Cannery Waste Site <br />1:1 Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />ID Sludge/Ash Site <br />CI CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />0 Small Generator CI Limited Hauler <br />2 - 10 CI 11 - 60 CI > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON p I E rlaS Day Ph (2539)55b 31-176) Night Ph (209)556 =34170 <br />6. DD El Surcharg FEE 0 Other FEE <br />; <br />/7 <br />PROGRAM ELEMENT 6.(n FEE <br />INSPECTOR # PERMIT VALID <br />CI Check # AMOUNT PAID <br />CI Cash REVIEWED BY Date <br />1:1 Food Handler <br />INVOICE # <br />)6'2- <br />MASTERFILE RECORD <br />/ <br />FORMATION PINK 48-02-034 <br />1/23/13 1"/. 103L.32—