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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> . <br /> El New Eli Program at Existing Facility ,/ <br /> ❑]slew Ell Progr4m and New Facility <br /> Facilit iD ��� 'Program Record ID /A7� <br /> Facility Address � Al <br /> * / <br /> d <br /> (Please Check the appropriate description and specify size number of units and pertinent information.} <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑Restaurant: Seating Capacity g ❑Wading Machines Number of Units <br /> [I Commissary ❑ Dry storage only with Food Preparation b <br /> L1 Retail Market---Square footage . ❑with Meat Market only [3 Multiple Departments ❑Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑Mobile Food Vehicle—­Make <br /> Sticker# <br /> Registration# License# <br /> ❑ Mobile Food Prep Unit—Maks Vehicle Type Color <br /> I.iccllse# Sticker# <br /> Registration# ❑ Ice Plant <br /> ❑Temporary Food Facility=Dates Of operation from to <br /> [3Special Event --Dates of operation from <br /> to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> k_CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(.2200)' . 9 <br /> Ll Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Eze:npt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit By-Rule Fixed Unit `❑pe/g' -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 F Lrrrrs <br /> Hous141G PROGRAMA(2400) <br /> [I IiotellMotei Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Ilousiog(2700)Use F,rrrnloyee Hausine/Lubor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTI N CONTR0L(30W) <br /> .❑ Environmental AssessmeDt [3 UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑non-NPUSEP Cleanup Site. ❑RNVQCB Cleanup Site "❑3'Yater Quality Remediation Site <br /> RECRP-AATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Peol/Spa ❑Natural Bathlug Arca <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ©Kennel <br /> Y'ATfOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> [3 Tattooing(412 1) ❑Body Piercing(4120) Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 13 Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant. ❑ ChemicaI Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ask Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA;Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑ Dutnpsfers>20 cu yd—Number of Units ❑FarmlRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled'Nursing ❑Large Generator Q Small Generator ❑ Limited hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ l 1-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePWSFAD46-02-003 R/ueApplieafion Form <br /> EMERGENCY NOTIFICATION FOP THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PICOGRAMELEMENr Z D FI I: ❑ SurchargeFr:E ❑ Other FFE <br /> INSPECTO z > PERMIT VALID . to ❑ Food handler <br /> ❑ Check AMOUNT PAID Date NVOICE#1. <br /> / <br /> ❑ Cash RFv1EWEDBY ACCOUNTINGOFFFICE Date i <br />