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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility ONew EH Program and New Facility <br />COL <br /> <br />Pro ram Record ID <br />Facility Address 2, c 2_,- (3 5r3 Z 0 <br />(Please check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />LeRestaurant Seating Capacity 0 Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units 0 Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Color <br />Sticker # <br />0 Temporary Food Facility --Dates of operation from to O Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />0 Tiered Permitting Facility ------> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site NPLJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPLJSEP 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 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 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 />0 Pumper VehicleRegistration # License # Capacity Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 1=1 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility O Process/Recycle Facility CIA Landfill Site <br />0 Refuse Vehicles ot of units) 0 Dumpsters 90 <br /> <br />> -- Cu yd (trot Units) O Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator O Limited Hauler <br />0 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 END 46-02-003 Blue Application Formn <br />CONTACT PERSON ' ---0,0.vC, Day PhF—T7---2-OCL 1/-10501 Night PhLk:O.___ <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />PROGRAM ELEMENT 6 2 4. FEE 0 Surchar FE 0 Other FEE — <br />INSPECTOR # 57 PERMIT VALID M.— 3 to I 3( 0 Food Handler <br />AmoUNT MI23 INVOICE # 3 , „ Date <br /> <br />//9 Date <br />MASTERFILE REC• I ORMATION PINK <br />CI Check # <br />1:1 Cash <br />49-02-034 <br />1/23/13 <br />Nt--/-!. /s(p155-30 <br />REVIEWED BY ACCOUNTING OFFICE <br />Aqk