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SAN JOAQUIN COUNTY E, 1 HEALTH DEPAINVINT <br /> _ MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing,Facility ❑New EH Program and New Facility <br /> Facility ID f/ cc I G I Pro ram Record IDOa-- <br /> Facility Address--"V3LI r qru'-� <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage 11with Meat Market only ElMultiple Departments ElPrepackaged Goods Onl} <br /> ElMobile Food Vehicle-----Make ` Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit -fake Vehicle Type Color <br /> Registration# License# to Sticker# <br /> 11 Ice Plant <br /> El Temporary Food Facility-----Dates of operation from <br /> El Special Event --Dates of operation from to 13 Produce Stand <br /> DAIRY PROGRAM (2000) <br /> F-1 Milk Dispenser --Number of Containers in Multi-Head Unit <br /> El Grade A Dairy El Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE 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 ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution-------Number of Units <br /> ❑ Ilotel/Motel-------Number of Units <br /> Ernplo�ee llousing(2700) Use Employee Housing,/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 IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> ❑ <br /> ❑ Pool Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facilin <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Kennel <br /> ElPoultry Farm -------�9axinnun number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing 01121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License# Capacity Vehicle# <br /> ❑ Pumper Vehicle -Registration# <br /> El Pumper Yard El Package Treatment Plant ❑ Chemical Toilets - Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Ag/Canner Waste Site 1:1Sludge/Ash Site <br /> El Landfill _0 Transfer Station y <br /> q11'nstchire Facility El Compost Facility <br /> ElProcess/Recycle Facility ElCIA Landfill Site <br /> ❑ Refuse Vehicles--Number ofUnits <br /> ❑ Ihnnp slers>20 cu yd----Number of Units ElFarm/Ranch Cleanup Site <br /> ---- <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited Hauler <br /> 13 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02- 10- 10------- ❑ 1 l -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 BlueApelication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR.km ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> 1 PERMIT VALID to ❑ Food Handler <br /> ❑ Check a AMOUNT PAID Date �J/ INVOICE# / <br /> C1 Cash REVIEWEDBY <�iz <br /> a ACCOUNTING OFFICE ZL'— Date b <br /> Masterfile Record Pink <br /> 48-0'_.0:1 <br /> 10/6-2i:,'3 <br />