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" - 'g <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH�Program and New Facility <br /> FacilityID d program Record ID !-L <br /> ' r yo� T7—)C . . <br /> Facility Address Q. bZA "r <br /> (Please Check the appropriate description and specify s�number of units and pertinent information) <br /> root] i'ROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:,. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines--Number of Units <br /> 11 Retail Market----Square footage ❑with Meat Market only 13 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 o_f operation from to ❑ Ice Plant <br /> Stand <br /> r] Special Event --Dates of operation from to 0-Produce <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dalry ❑ Milk Dispenser Number of Containers in Multi-Head Unit <br /> w a CUPA ❑State Facility Surcharge(2399) <br /> IIA7,ARDOUS'1VASTE PROGRAM(2200)' i <br /> ❑Hazardous Waste Generafor- Tons Generated Per Year 0 Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(221 s) ❑ Silver Only(2222) D plianee Recyclers(2217) <br /> Tiered Permitting Facility- - ❑Conditionally Authorized(CA) nditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit Pe t-By-Rule Household Hazardous Waste <br /> XIUNDERGROUND <br /> BOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST STORAGE TANK(UST)PROGRAM(2300)Use UST 4 and B rrns <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteilMotel Number of Units ❑Jill or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housinr/Labor Camp Amlication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ElLocal HW Cleanup Site, ❑NPLISEP Cleanup Site 11 UIC Site <br /> 0 Abandoned MY Site 13non-NPIJSEP Cleanup Site ❑R)vQCB Cleanup Site '❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolslSpas at Facility. ❑Pool ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(40D0) <br /> ❑Poultry Farris Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 1:1 Tattooing(412 1) ❑Body Piercing(4120) ❑ Permanent Cgs <br /> mcGcs(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ElPumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station 13 Ag I Cannery Waste Site El Sludge/Ash Site <br /> ❑Waste Tire Facility 11 compost Facility 11ProcesslRecycle Facility [ICIA,Landfill Site <br /> G❑Refuse Vehicles--Number of Units ❑Dumpsiers>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skiiled Nursing ❑Large Generator Small Generator ❑Limited Usuier <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--O 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 219 FEE ❑ Surcharge FEE ❑ Other FEE <br /> IHsrEcrott# it IT VAUD . to ElFood handler <br /> ❑ Check# AMOUNT PAID Date INVOICE#p- <br /> ❑ Casb REViEwF-DD ACCOUNTING OFFICE Date p <br /> Macr rflr R�rnrrl PinL- <br />