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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI1 DEPARTIIIENT <br /> MASTERFIL,E RECORD-INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> [:F:acility ID F?q'v D, �P-1 0 D' Pro rarriRecord ID FY-0 631Q59 LAJ <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) l�. <br /> FOOD PROGRAM(1600) 1 <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Drystorage 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 ❑ Ice 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-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)` i <br /> ❑Hazardous Waste Gerierator.— Tons Generated Per Year ❑Recycle/Exempt system(2299) <br /> ❑ CRT Offsite Handlers(221 s) ❑ Silver Only(2222) ❑ Appliance Reeyelers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen-nit-By-Rule Fined Unit ❑ Perrnit-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{awns <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/lilotel Number of Units "❑Jail or Exempt Institution Number of Units <br /> Employm Ifousina-(2700)Use Emplayee dfausing< gbor 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 IIAV Site ❑ non-NPL/SEP Cleanup Site ❑R\VQCB Cleanup Site ❑ 3Vater Quality Remediation Site " <br /> RECREATIONAL HEALTH 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) ❑ Permanent 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 /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> iVaste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farmiltanch 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) Use Pff'SEUTD M-02-403 BlueApplica(ian For7n <br /> EMERGENCY NOTIFICATION FOR THls FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_ _ Day Ph Night Ph <br /> i <br /> PROGP-01 ELEIIIENT �!,�v FEE ❑ Surcharge FEE ❑ Other FEE - <br /> INSPFCTOR# _13j:�y__ PErMJTVALID __- to ❑ Food Handler__ <br /> 0 Check t'- AATOUI-i'r P ul) - _ Date h-VOICE# - - -- <br /> � � l <br /> El Cash 3:EVIEwFli By ALCOIJNTI1:G OFFICE Date <br />