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Program Record ID <br />Facility Address 1117 C. Wrtor, ,C-11)CktDr CA q")(A9 <br />Facility ID FAT17 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FfatirM <br />New EH Program at Existing Facility 1% New EH Pro ram and New Facility <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 Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0/Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # F <g• I bcp Sticker # <br />Temporary Food Facility --Dates of operation from to CI Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to CI CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy CI Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <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 />CI Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />CI Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) CI 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 CI UST-CAP Site CI Local HW Cleanup Site El NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site CI 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 />CI Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station El Ag/Cannery Waste Site El Siudelkaft.a , <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility 0 CIA • ivr <br />El Refuse Vehicles (rt or Units) El Dumpsters > 20 cu yd (4 of units) El FarZaRretaiir teSite <br />MEDICAL WASTE PROGRAM (4500) BET' <br />El Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator CI Small GeneratoraiXteidiaf9er <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 0 11 - A414 Jakeu9illa,vgr,etors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form xar.. tiN ENVI " <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM '`411-7.1i <br />R <br /> DEART;i4TAL r <br />CONTACT PERSON uy )---e !,(91-Cf-'r_Day Ph Of.--,9*/&ANight Ph <br />PROGRAM ELEMENT IC/9;2) FEEV);3 • 01-) 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # PERMIT VALID to 126 0 Food Handler .2 ,0 <br />Check # AMOUNT PAID Date INvoicE# <br />Cash REVIEWED BY Loam ACCOUNTING OFFICE •i;)./,; Date <br />48-02-034 MASTERFILE ECORD INFORMATION PINK <br />1/23/13