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SAN JOAQUIN COUNTY EN 0NMENTAL HEALTH DEPARTWNT <br /> NIASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing,Facility 14New EH Program and New Facility <br /> Facilitv ID 0 C) ( L�(O3 Pro ram Record ID RDS c 2 <br /> Facility Address �8 q S, A!� <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 ❑ Nyith 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# ' "`�jeW1 . Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from _r6 ele I S ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from Ca+ tt-I S '5(fie ° _ ❑ Produce Stand <br /> DAIRY PROGRAM (2000) (°-'V&VX der A 10I <br /> ❑ Grade A Dairy ❑ Grade B Dairy -10,faA1fA(�^ ��Jt� iners in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) U <br /> ❑ Hazardous Waste Generator------------Tons Generat !cycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Or,.y k_-, — �r,t„..,,ce Recyclers (2217) <br /> Tiered Permitting Facility------------------11 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/illotel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee llousing(2700) Use Employee llousinj?/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HN1'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IINV Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ElPool 11Spa [IOut of Service Pool/Spa ❑ Natural Bathing:area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry Farm -------Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11Landfill El Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> 'Waste"fire Facility El Compost Facility ElProcess/Recycle Facility El CIA Landfill Site <br /> El Refuse\'eliicles--Numbreof[)nits ElDuml)sters>20 cu yd----Number of Units _ EI 1"11-111/RanchuCleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care ❑ Skilled Nursing El Large Generator ❑ Small Generator ❑ Limited Hauler <br /> El Transfer Station El Veterinary Clinic 11 Common Storage Facility----❑ 2- 10-- - - El 1 I -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P{VS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON if Day Ph Night Ph <br /> LPROGii.-vNi EI.E.NIENT -7qo FEE ❑ Surcharge FEE ❑ Other FEE <br /> PEcrog# 0060 PERM[TVALID to ❑ Food Handler <br /> Check a ANIOUNI'PAID DateINVOICE# <br /> Cash REVIEWED 131'JP_ OFFICE Date <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 1016%2003 <br />