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SAN JOAQUIN COUNTY —,JVIRONMENTAL HEALTH DEPAt\I MENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ENew EH Program and New Facility <br />Facility ID -r40022 772— Pro ram Record ID <br />s C_"( 4.7(lo'ty0 <br />Square Footage <br />El with Food Preparation <br />EVending Machines Number of Units <br />1=1 w/Meat Market only El Multiple Departments El Prepackaged Goods Only <br />El Mobile Food Prep Un ehitle Type Color <br />ry 'retaert.,Regitipn#r1i g p_- (I 'cense # <br /> Vehicle Type <br /> Sticker # 2.31Y <br /> <br />Color <br />Registration # License # Sticker # <br />CI Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to E CFO 0 A E B <br />DAIRY PROGRAM (2000) <br />0 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 />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility El Program 3 Facility <br />0 Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) LI CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PER HHW (2236) <br />0 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 />El Environmental Assessment 0 UST-CAP Site El Local NW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Cl Abandoned HW Site LI 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 CI 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) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) E Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard LI Package Treatment Plant LI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station <br /> El Ag/Cannery Waste Site <br /> 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility El CIA Landfill Site <br />LI Refuse Vehicles (# or units) <br /> <br />LI Dumpsters > 20 cu yd (# of Units) <br /> LI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 0 Acute Care El Skilled Nursing C7 Large Generator 0 Small G <br />Transfer Station CI Veterinary Clinic El Common Storage Facility CI 2- 10 Li 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSO\ 4-070' v- 01/2_ <br />EMARGTCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph Night y Night Ph <br />Facility Address <br />(Please check the appropriate description and specify size, nigmber of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />LI Restaurant: Seating Capacity <br />1=1 Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />PAYMENT <br />RECEIVED <br />J4N1 9 2015 <br />SAN <br />JOAQUI N COUNry ENVIR <br />HEALTH OmENTAL DEPARTmEArr <br />Food Handlers Course required: YES ID No 0 <br />kD537 ,v,-e) <br />enerator E Limited Hauler <br />LI > 60 generators <br />PROGRAM ELEMENT (633 FEE 0 Surcha ge FEE Ei Other FEE <br />INSPECTOR # '1 3 6./ PERMIT VALID l 9 T to I 5— 0 Food Handler <br />Check # AMOUNT PAID il itgb Date S--- INVOICE # -2435.2.7-____ <br />k Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02- <br />/5— <br />, ,,),, -4034 MASTERFILE REC ,D INFORMATION PINK