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SAN JOAQUIN COUNTY EWIRONMENTAL HEALTH DEPATANIENT <br />l MASTERFH.E RECORD INFORMATION I;ORM p <br />❑ New EH Program at Existing Facility LKew EH Procram and New Facility <br />r'actut it) uVj!:)6gtzLe Program Eecord ID Y A0 / 7?� <br />Facility Address S <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 <br />❑ Special Event --Dates of operation from to <br />❑ lee Plant <br />❑ 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 PROGRA 00) <br />—2 Hazardous Waste Generato------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (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 of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) - <br />❑ Hotel/Motel- ----Number of Units ' ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Housine/Labor Camp 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 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 (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # <br />License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment <br />Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units <br />❑ Dumpsters > 20 cu yd ---Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled <br />Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic <br />❑ Common Storage Facility ----- 02-10 ------- ❑ 11 - 60 ------ 1:1 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY N <br />TIFIGATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON fjWWAN CO/ <br />Day Ph Night Ph <br />PROGRAM EL�9EMENT.�7,� LZG FEE ifWO <br />1:1 Surcharge FEE El Other FEE <br />INSPECTOR # � PERMIT VALID <br />to ❑ Food Handler <br />❑ Check # AMOUNT PAID <br />Y <br />Date 7 INVOICE # - <br />❑ Cash REVIEWED BY <br />ACCOUNTING OFFICE Date <br />48-02-034 <br />Mast de Record Pink <br />10/6/2003 <br />