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1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTh NT <br /> MASTERFH.E RECORD INFORMATION FORM <br /> PAYMENT <br /> ❑New EH Pro am at Existing Facility ❑New EH Program and New Facility RECEIVED <br /> Facilit ID ✓A Ott 1,`1,1--1'' Program Record ID <br /> AUG 14 2008 <br /> FacilityAddress '7`< .l'tW 7 SQA s-rw-Pie+ , <br /> (Please Check the appropriate description and specify s�number of units and pertinent information.) SAN OCOUNTY <br /> ENVVIRIRONNMM ENTAL <br /> FOOD PROGRAM(1600) HEALTH DEPARTMENT <br /> ❑Restaurant: Stating 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 11 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 /> W Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(22i s) ❑ 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 of AST <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units 11Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) _ <br /> ❑EnAroumeutal Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLlSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑P9ol ❑ 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 /> ❑ 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 ❑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--El 2-10—1111-60—❑>60 generators <br /> PUBLI C WATER SYSTEM PROGRAM(4600)Use Plf'S EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON j U(I 0,v\- 0 d,.0A Day Ph Night Ph <br /> PROGRAM ELEyMFNTT _721& FEE D! ❑Surcharge FEE El Other FEE <br /> INSPECTOR# `cV`G' ,00 PERMIT VALID to itI a'l. g' ❑Food Handler <br /> KiCheck# AMOUNT PAID /9& ,� Date INVOICE# <br /> ❑ Cash REYmEWEDBY A4 f\/ ACCOUNTING OFFICE Date <br /> R,nM Piny <br />