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SAN JOAQUIN COUNTY *FORMATION <br />RONMENTAL HEALTH DIVISIC-' <br />MASTERFILE RECO FOfH 00 69) <br />❑ New EH Program at Existing Facility "New EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address =\?-o 'V--- . , c <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Vending 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 ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARJJOUS WASTE PROGRAM (2200) <br />G/Hazardous Waste Generator ----------Tons Generated Per Year 5 % ❑ Recycle / Exempt System <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -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 />❑ llotel/Motel-------Number of Units ❑ Jail or Exempt Institution -------Number of Units <br />Employee Housing (2700) Use Employee HousinglLabor Camp Application Foran <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4 100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper 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 ❑ Ag / Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units ❑ Dumpstcrs > 20 cu yd ----Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 112- 10 ------- ❑ 1 1 - 60 ------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS E110069 Bhie Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELF MENT FEF, ❑ Surcharge FFF ❑ Other FEE <br />INSPECTOR # PERMIT VALID to ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash RGVIEWED uY ACCOUNTING OFFICE Date <br />FI 10069 Pink Form Rev. 02/25/03 <br />