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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at Existin Facility ew EH Pro and New Facility <br /> Facilit H) � Pro ram Record ID O <br /> Facility Address J41 �� Ilc f'Y�Of�7r7� Ua�9 LU <br /> (Please Check the appropriate description and specify s, M number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required.. Yes❑ No El <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 ❑Gnde B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> H4zARDOUS WASTE PROGRAM(2200) . d i <br /> azardous Waste Generator. Tons Generated Per Yeaz ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) 2, <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazar <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> -UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UNT A and B forms <br /> HOUSING PROGRAM(2400) _ <br /> ❑ IIotel/Motel—Number of Units []Jail or Exempt Institution—Number of Units <br /> Employee housing(2700)Use Employee Ifousinp/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) _ <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Loin HW Cleanup Site, ❑NPLrSEP 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 ❑P901 ❑ 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(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 13 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 ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,Latu fill 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 Can ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS EfID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day PhO -/�ZNightPh .Sa-O`e� <br /> PROGRAhf ELEMENT o�e�9CJ FEE l ❑ Surcharge FEE . ❑ Other FEE <br /> INSPECTOR#iia PERMIT VALID to / ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE#�2/� <br /> 0 cosh REVIEWED BY 3/� ACCOUNTING OFFICE Date . / <br />