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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 11IASTERFILE RECORI)INFOPA.[AATION FORM <br /> ❑New EH Program at Existing Facility ANew EH Program and New Facility <br /> Facility ID DD ��, ��- " Pro ram Record ID �05.3�, I <br /> facility Address � l5�te� �. �;c t L� Aite -- <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Drystorage only Elwith Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail lancet—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€t 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 ❑Milk Dispe-user—Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑hazardous Waste Gencrat.or.--Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑CR`1-'Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ®Pcnrnit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(ASL)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HotellMotel Number of Units -❑Jail or Exempt institution Number of Units <br /> Employee Housing(2700) Use Fmployee Housinjz/Eabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ® UST-CAP Site ❑Local MV Cleanup Site ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned ITV Site ❑ non-NPLISEP Cleanup Site ❑RiVQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL tIEALTH PROGRAM(36W) <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(4121) ❑ Body Piercing(4120) ❑ Perrnauent 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 /> ❑�i L_ andfill E] Transfer Station 11 Ag/Cannery\Vaste Site ElSludge/Ash Site <br /> �FVaste Tire Facility ❑ Compost Facility ❑ProcessfRecycle 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 El Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UsePTVS,GHD 46-02-403 BlueApplica(ion Fort <br /> F-MERGENCY NOTIFICATION FOR THis FACILITY AND/Ort PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEM NT474/0 — P E E El Surcharge_Fee ElOther FEE — <br /> INSPFCTOR# c;26,�zV PERMITVALID to ❑ Foo.dHandler <br /> __ <br /> El Check f` .Ajm0Uirr P kf1) Date <br /> Cash R_EVIEV(FD BY ACCOUNTING OFFICE <br />