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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> MASTERFILE RECORD INFORMATION FORM MAR <br /> ❑New EH Program at Ezistin Facility ew Eli Program and New Facility _ 'S 2007 <br /> Facility ID Pro ram RecordI.DAnr Y HAEENVI ONMEIOU ly <br /> Facility Address til 3 n A 2 ���r ( nEPARTMENT <br /> (Please Check the appropriate description and specify EIK�,number of units and pertineol information) <br /> FOOD PROGRAM(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 /> ❑ 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) a>-he✓� <br /> IIA74RDOUS WASTE PROGRAM(2200) A <br /> Ilazardous Waste Generator. Toru Generated Per Year ❑Recycle/Exempt System(2299) <br /> CRT Offsite Ilandlers(2218) ❑ Silver Only(2222) _ ❑Appliance Recyclers(2217) <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 oCAST - <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B lorms <br /> HOUSING PROGRAM(2400) - <br /> ❑Ilotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Fmploree Hausine/fa6or Camra Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑USr•CAP Site ❑Loral BW Cleanup Site ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ��1�, <br /> Number oCPools/Spas at Facility 11 Pool ❑ Spa 11 Out of Set1V#a€(P� pa ❑Natural Balding Area <br /> VECTOR CONTROL PROGRAM(4000) _ <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> r,Alli? f? �(i,-, , <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) - ❑yerni"Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) '!SERVICES <br /> ❑ Pumper Vehicle—Registration# — License# Capacity Vehicle 41 <br /> ❑ Pumper Yard 11 <br /> Package Treatment Plant ❑ Chemical Toilets—Number of Units - <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site - <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle 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 /> ❑ Primary Care - ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-16-11 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS E11D 46-01-003 Blue Appficalion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON �'I C S O{�! Day PhVr r- 0 0DNight Ph <br /> PROGRAMELEMENT -2--2—:7— _ FEE ❑ SurehargeFE- ❑ Other FEE <br /> INSPECTOR# /, ) 1 PERMIT VALID �' to 0 ❑Food Handler <br /> AMOUNT PAIDa�D G Date 3 b INVOICE# / ) <br /> 11Cash REviEwED By Accour TtNO OFFICE Date 3 / (/ <br />