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SAN JOAQUIN COUNTY E 'IRONMENTAL HEALTH DEPAR" :NT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 0New EH Program and New Facility <br />Facility ID DO2._cas-y- Program Record ID -Pr..:6-114(4,13 <br />Facility Address 11 i1 S . 0.6 on SI-- • OA 011 -7-0‘..0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No E <br />E Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage Li w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />Pr Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # NI IQ 33 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to CI CFO 0 A El B <br />DAIRY PROGRAM (2000) <br />Li Grade A Dairy 1=1 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />Li CalARP Program CI Program 1 Facility 0 Program 2 Facility 1=1 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) CI PBR HHW (2236) <br />1:1 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El 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 0 UST-CAP Site 0 Local HW Cleanup Site CI 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 CI Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) Li Mechanical DSPS Notification (4115) El Body Art Facility-SiclikVIVIRW <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp EveviteellVEID (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity WING/ t 2019 <br />Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Wir <br />COUN <br />SOLID WASTE PROGRAM (4400) SAN JCAQUIN <br />TAELN <br />0 Landfill 0 Transfer Station Ag/Cannery Waste Site 0 <br />CI Waste Tire Facility 0 Compost Facility E Process/Recycle Facility CI CY L.Nlavit:d°fiNIIMSEitNe <br /> Silk 44itONAETNI T <br />Refuse Vehicles ut of Units) Li Dumpsters > 20 cu yd (# of Units) E Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator D Small Generator 0 Limited Hauler <br />Cl Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 I=1 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fon-n <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON BenyArym Movior,\ Day Ph 20V Night Night Ph Z7,7- 7,/2 •G'119 <br />PROGRAM ELEMENT \ W5 FEE El Surchar e F 0 Other FEE <br />INSPECTOR # (z) PERMIT VALID 2- to I ). Li Food Handler <br />1:1 Check # AMOUNT PAID 4f Date INvoicE# 3 0 <br /> <br />REVIEWED Bfl:WY\ ACCOUNTING OFFICCash Date 7 / <br />1/23/13 sd-ttb-r. <br /> MASTERFILE RECO INFORMATION PINK 18(-02-034