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SAN JOAQUIN COUNT' ENVIRONMENTAL HEALTH DEPARXMINT <br /> M <br /> INIASTERFILE RECORD INFORATION FORi\1 _ <br /> -New EH Program at Existing Facility XNew EH Program and New Facility <br /> Er,acilify ID-- �Program Record II➢ �az) <br /> Facifi[T Address :RW,5e21 c_ j—T'��j q!53e)�-/, <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1500) <br /> ❑ Restaurant: Seating Capacity Square Footage Food handlers Course required: YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Wending Machines—Number of Units <br /> El Retail Market—Square footage ❑with luteal Market only El Multiple Departments El Prepackaged Goods Only <br /> El 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 /> ❑ TemporaryFood 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 Contained in Multi-Head Unit <br /> CUPA ❑ S(atc Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ hazardous Waste C�enerator----- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers (2216) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ---❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Penrait-lay-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 FIST A and F larrru <br /> HOUSING PROGRAM(2400) <br /> ❑ Iiotenlotel Number of Units ❑Jailor Exempt Institution Nurnber of Units <br /> ]Employee Irousirag(2700) Use Fmployee e fousirnt? rbor Camp Appficatiott Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EuAronmentat Assessment ElUST-CAPSite El Local II)V Cleanup Site. ElNPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ tion-NPL/SEP Cleanup Site ❑R�g'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ® Pool ❑ Spa ❑Out or Sen'ice Pool/Spa ❑ Natural Ilathing Arca <br /> VECTOR GOHTROL 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 Velxicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Ward ❑ Package Treatment Plant- ❑ Chemical'Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfall ❑ Transfer Station ❑ Ag I Cauvery Waste Site ❑ Sludge/Ash Site <br /> .-Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ FarmflUnch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 11Transfer Station ❑ Veterinary Clinic 11Common Storage Facility---D 2-10--FIJI -60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIG'4F111)d6-01-003 BlueApplicalion For-ra <br /> EMERGENCY NOTIFICATIM4 FOR Tills FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT�(�?_ FEE ❑ Surcharge FEE ❑ Other FEE <br /> Irvsrccroa# a t2o PE-KNIIT VALID to ❑ Food Handler <br /> ❑ Check i AMOUNT PAID _ _ Date hiv010E It ^ _ <br /> El Cash RE`;'IEwED BY ACCOUNTING Of1=10E Dale (Q V <br />