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HEALTH DEPARTMENT RFCE111!f6 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HE <br /> MASTERFILE RECORD INFORMATION FORM <br /> MAY 52008 <br /> ❑New EH Program at Existing Facility VfNew EH Program and New Facility SAN JO <br /> _ ou <br /> EN AQU/NR fD�Facilit ID 1 P73 Program RecordID <br /> Facility Address S 7`ec-C,_,-V ✓ <br /> TAL <br /> MEivr <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❑ No0— <br /> ❑ Commissary ❑ Dry storage only ❑ with 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# License# Sticker# <br /> ❑Temporary Food Facility—Dates of operation from = to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to X 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 WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator.---- Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 s) ❑ 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee 7fousinz/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 /> Number of Pools/Spas at Facility ❑P901 ❑ 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(412 1) ❑ 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 /> ❑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--[] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P11SF.11D46-02-003 Blue Application Form <br /> EMERGENCY NOT1rrCAT10N FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON l�'r } ��s L C d C' E�-4-^'- I Day Ph 1Y Night Ph <br /> PROGRAM ELEMENT 60TFEE d ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# jjW 1 '4 2_0 PERMIT VALID .s S D to CS 3.�/ o ❑ Food Handler <br /> ❑ Check# A-MOUNT PAID ky 0 0 0 Date INVOICE# <br /> Cash REVIEWED BY '2 C ' 1 2/ ACCOUNTING OFFICE Date <br />