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SAN JOAQUIN COUNTY ENVIRONMENTAL:HEALTH DIVISION <br /> 1MASTERFILE RECORD INFOILMATION 170"1(EH 00 69) <br /> ❑ New EH Pros=at Existing Facility ew EH Progarn and New Facility <br /> Facility IDi r� �'._ t c l ' Program Record ID <br /> Facility Address A"' cap --"o znoys, vkt -� <br /> (Please Check the appropriate description and specify side number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Searing 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 <br /> to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from <br /> 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---------------Tori 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 /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST.4 and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> C1 HoteVivlotel-------Number of Units <br /> Employee Housing(2/00) Use Employee Ho sit e/L hor Cama Application Form <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 PooWSpas at Facility Cl Pool ❑ Spa [1 out of Service PooVSpa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle-Registration# <br /> License# Capacity. <br /> ❑ Pumper Yard C3 Package Treatment Plant ❑ Chemical Toilets—Number of Units�— <br /> t <br /> SOLID WASTE PROGRAM(4400) ❑ Slud elAsh Site <br /> ❑ Landfill C1 Transfer Station ❑ Ag l Cannery Waste Site g <br /> ❑ Process/Recycle Facility ❑ CIA Landfdl Site <br /> ❑ Waste Tire Facility ❑ Compost Facility 11Fann/Raach Cleanup Site <br /> ElRefuse Vehicles-Number of Units C1Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Stooge Facility —❑ '-- 10— <br /> ❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form - <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> ^X -V- FEE ❑Surcharge FEE C3 other FEE <br /> PROGRAM ELEMENT - ❑ Food Handler-- <br /> INSPECTOR# 17=,!:Q0\ PERMIT VALID�— [O <br /> ❑ Check# AMOUNT PAID �� Date INVOICE# <br /> ❑ Cash REvMVEDBY ACCOUNIING OFFICE ��L Date �� <br /> Rev.0710799 <br />