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ou sa�S O.A!5i rv� <br /> 1_. � <br /> SAN JOAQUIN COUNTY EN VIRONv1ENTAL HEALTH DEPAR' E <br /> NT <br /> MASTERFELE�ECORD INFORIMATION F0 NJ <br /> New EH Pro--ram at Existing Facility <br /> ❑New EH Pro am and New Facility <br /> Program Record ID V17Do� 3� <br /> Facility ID V <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: YES❑ No ❑ <br /> ❑ Restaurant: Seating Capacity Square Footage <br /> ❑Vending <br /> El Commissary C3 Dry storage only <br /> ❑ with Food Preparation Machines--Number of Units <br /> C1 with Meat Market only ❑ Multiple Departments ❑ColoPrepackaged Goods Only <br /> 11 Retail Market----Square footage Vehicle Type <br /> ❑ Mobile Food Vehicle-----Make Licenser Sticker# <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from to 11Produce Stand <br /> C3Special Event --Dates of operation from <br /> DAIRY PROGRAM(2000) ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ Hazardous Waste Generator------------ ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222����) <br /> [I Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> Tiered Permitting Factlitv------------- <br /> ❑ Permit-By-Rule Fixed Unit ❑�rmit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of ASTM, <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution------Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700) Use Employee Hotrsin, Labor Camp Application Form <br /> UNDERGROUND INJECTION CONTROL(3000) [IUIC Site <br /> SITE MITIGATION(2900) <br /> ❑ Environmental Assessment ❑ UST-CAP SEP Cleanup Ste Local H�❑CR"QCBtCleanup❑Si QPL/SE❑ Water Quality Remediation Site <br /> ❑ Abandoned HW Site ❑ non <br /> RECREATIONAL HEALTH PROGRAM(3600) 0 Natural Bathing Area <br /> Number of pools/Spas at Facility <br /> ❑ Pool ❑ Spa(3600) out of Service pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm-----Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> g [I Permanent Cosmetics(4122) <br /> El Tattooing(412 1) ❑ Body Piercing('-1120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> ❑ Pumper Vehicle--Registration# ❑ Chemical Toilets-------Number of Units <br /> ❑ Pumper Yard 11 Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) 0 Sludge/Ash Site <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site C1 CIA Landfill Site <br /> ❑ Landfill ❑ Process/Recycle Facility <br /> [I Waste Tire Facility ❑ Compost Facility ❑ Farrn/Ranch Cleanup Site <br /> ❑ Dumpsters>20 cu yd----Number of Units <br /> 11 Refuse Vehicles--Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator [I Limited Hauler <br /> ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator [] 11 -60-----❑ >60 generators <br /> El Primary Care <br /> ❑ Common Storage Facility----- <br /> 2- 10------- <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS END 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ight h <br /> Day Ph <br /> CONTACT PERSON ❑ Other FEE <br /> p, FEE ❑ Surcharge FEE <br /> EPROGRANI ELENIENT - I to ❑ Food Handler <br /> OR# 8 PERMIT VALID INVOICE#ANIOUNT PAID Date <br /> # Date jREVIEWED BYACCOIJ`1 TING OFFICE Mastele Record Pink <br /> 48-02-034 <br />