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4W <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTImENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility XNew EH Program and New Facility <br /> Facilit y ID Pro ram Record <br /> �' <br /> i yr ' <br /> acility Address �`1` ny) <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 ❑ Ice Plant <br /> ❑ Special Event -Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Mill:Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator.------------Tons Generated Per Year ❑Recycle I 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 /> ❑ Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) - '• 111-1 a r—rIZOL60W) <br /> ❑ Environmental Assessment ❑iL Cleanup Site ❑UIC Site <br /> H <br /> ❑Abandoned W Site 11i AfflPROGRESS hater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRA RAIL SERVICES <br /> Number of Pools/Spas at Facility. ACaterpillar Company ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(40Q <br /> ❑Poultry Farm Maximumnun-A Deepak Bhardwaj 11 Kennel <br /> TATTOO BODY PIERCING,PERMI Ramp Manager <br /> ❑ Tattooing(4121) rmanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) 6540 Austin Rd. Office 209/460-6036 <br /> ❑ Pumper Vehicle—Registration# Stockton,CA 95215 Cell 209/456-2080 Vehicle# <br /> 11 Pumper Yard <br /> Email:dbhardwaj@progressrail.com Fax 209/460-6044 .lumber of Units <br /> � <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-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 D Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# p <br /> El Cash REVIEwm BY ACCOUNTING OFFICE Date -730 0 <br />