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l r <br /> SAN JOAQUIN COULNTY T -rIRONILENTAL HEALTH DIVE" N <br /> MASTERFILE RECORD LNFORNtiLATION FORAM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Programand New Facility <br /> Facility ID "1 Program Record ID <br /> Facility Address Mc.( ✓1 S+- , mlut` e—ra G� <br /> (Please Check the appropriate description and specify siM number of units and perrinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YFs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail liarket--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ :Mobile Food Vehicle---Make Vehicle Type Color <br /> Regisrrarion R License# Sticker T <br /> ❑ iviobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License: Sticker T <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dares of operarion from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> XABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGPLANI(2300)Use UST A and 8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUNtotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emplovee HousbrKabor Cama Aoalicarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site Cl UIC site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility El Pool ❑ Spa C3 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [1 Poultry Farm Maximum number of birds Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Regisrrarion T License R CapacityVehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3C1 Landfill ❑ Transfer Station Ag/Cannery Waste Site C1Studge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcessJRecycle 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 /> C1 Primary Care C1 Acute Care El Skilled Nursing C3 Large Generator C1 Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ It -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Ayolicarion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA.VI ELEMENT 23 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR PERNIR VALID to ❑ Food Handler_ <br /> ❑ Check Amon,-r PAID Date INVOICE T <br /> ❑ Cash REVteweD BYC4t(A3 13 ACCOuvrNG OFFICE Date / <br /> Rev.07/07/99 <br /> EH 0069 PI`1'ti FoiLM.do< <br />