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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />E JOAQUIN COUNTY Facility Address S (M(-1-&-12,nip <br />(Please check the appropriate description and specify size, number of units and pertinent information.) HEALTH DEP,-„ALk c'TfitIELNT <br />NV1RONMENTA <br />Facility ID ."-il,()52_S/ 3`i <br />New EH Pro ram at Existin Facilit <br />Program Record ID 7e 05-4 o3 b <br />MNew EH Pro ram and New Facility <br />3AN <br />PAYMENT <br />RECEIVED <br />APR 092024 <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> Vehicle Type Color <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />ya Mobile Food Prep Unit-- Make <br />Registration # <br />License # Sticker # <br />Vehicle Type Color <br />License # 4 c.1571/47- (o3q3 Sticker # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />to 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <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 />0 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 NPUSEP 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 0 Spa 0 Out of Service Pool/Spa 0 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 />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />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 # <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 Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />e I 1---r/v) y c) 71( DaY •;)Ci(-i - Li - (i-j-5.-Night Ph O9 -( L2 -95-g- 5"-- <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />CONTACT PERSON 'g <br /> <br />PROGRAM ELEMENT (7 3 FE <br />INSPECTOR* „ PERMIT VALI <br />Check # <br /> dor <br /> <br />, AMOUNT PAI <br />Cash REVIEWED BY <br />48-02-034 <br />1123/13 <br />DK) 0 Surcharg <br />to <br /> Date <br />ACCOUNTING OFFICE <br />dzx 17/L9)763 <br />FEE 0 Other FEE <br />0 Food Handler <br />INvoicE# 3 2_ <br />Date 2:7 <br />MASTERFILE RECOwD INF RMATION PINK