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SAN JOAQUIN COUNT']ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility MNew Ell Program and Nmy Facility <br /> Faci� -,40,44,5 P ram Record ID P FILE C <br /> Facility Address 0 W, Porgy 12A 11 SL'&6 (A 15201 <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 Elwith Food Preparation ❑Vending Machines—Number of Units <br /> ElRetail 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 ❑ lee Plant <br /> ❑ Special Event --Dates of operation from 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 /> IIAZARDOUS IVASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator---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 ❑Pernut-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(arms <br /> ROUSING PROGRAM(240'0) <br /> ❑ HotelfMotel Number of Units ®Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee dIousin,*4xbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL.(3000) <br /> ❑ EnAronmental Assessment ❑ UST-CAP Site ❑ Local 1I)V Cleanup Site. ❑ NPL/SEP Cleanup Site El UIC Site <br /> ElAbandoned IIW Site 11non-NPI.(SEP Cleanup Site 13RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility, ❑Pool ❑ Spa ❑Out of Service PoollSpa ❑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 Plaut ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Asti Site <br /> Od 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 ® Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---El 2- 10 ❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UscPHS ETTD46-02-003 BlueApplica(ion Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRoc;RAn1 ELEMENT L�n tAFEE ❑ Surcharge.Fee ❑ Other FEE <br /> INSPECTOR# PERM17'VALID . to El Food Handler <br /> ❑ Check# AI•IOUNT PAID Date INVOICE# _ <br /> a <br /> ❑ Cash_ REVIEWED BY LIj- l() ACCOUNTING OFFICE '�✓,.� Date <br />