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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at ExistingFacility ❑New Eli Program and New Facility <br /> Facility III ,�(d /, Pro ram Record ID <br /> Facility Address —I`6�3 /J Al V Tir/ <br /> i <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vendiag Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant _ <br /> ❑Special Event —Dates of operation from - to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - <br /> ❑ Grade A Dairy ❑ Gmde B Dairy ❑Milk Dispenser—Number of Containers in Multi-Bead Unit <br /> - CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> I <br /> ❑Hazardous Waste Generator--Tons Generated Per Year -❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(22 18) ❑ Silver Only(2222) _ ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Pe ' -By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST - - <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) - <br /> ❑ Hotel/Motcl—Numbs of Units ❑Jail or Exempt Institution—Number of Units <br /> Employer Housing(2700)Use Emploree Ifousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local BW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑Spa ❑Out of Service PoollSpa ❑ Natural Bathing Area <br /> VECTORGONTROL PROGRAM(4000) - <br /> ❑ Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle 9 - <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag l Cannery Waste Site ❑ Sludge(Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm(Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—❑ 2-10—❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PR'SEHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON // Day Ph Night Ph <br /> M <br /> PROGRAE,r�LEMENT_ -Z FEE 11 SurchargeFEE [I Other FEE <br /> INSPECTOR le- j iu 9 PERMr_VALID to ❑ Food Ilandler <br /> ❑ Check# AMOUNT PAID Date INVOICL# p <br /> 0 Cash REVIEWED BY ACCouN-riNG OFFICE LL Date �� �/ <br />