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--SAN JOAQUIN COUNTY ENVIRON NTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ew EH Program and New Facility <br /> Facility ID Program Record ID 12 7 1 <br /> Facility Address 1 7,`-{ S t fI c2 Ck <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 El No El <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 Vehicic'I'ypc Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to 11 Ice Plant <br /> El 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-Head Unit <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)(23 90) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> 11 Hotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units <br /> Employee[lousing(2700) Use Employee HousinQlLnhar Camp Application Farm <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 HW 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 ❑ Pool El Spa ❑ Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [1 Kennel <br /> ElPoultry Farm -------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 13 Tattooing(4121) El Body Piercing(4120) 1:1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle -Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> [3 Landfill El Transfer Station El Ag/Cannery Waste SitelE, ❑ Sludge/Ash Site <br /> ❑ Process/Ree cle Facility ❑ CIA Landfill Site <br /> Waste Tire Facility ❑ Compost Facility Y Y <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 El Acute Care 13 Skilled Nursing ❑ Large Generator 13 Small Generator 1:1 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----E] 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> FINSPECTOR <br /> EMENT "l-TIC, FEE ❑ Surcharge FEE 13 Other FEE <br /> PERMrr VALID to ❑ Food Handler <br /> AMOUNT PAID Date INVOICE# <br /> IZL'VIEWED nv �� 3�23 G.S ACCOUNTING OFFICE Date 3 oZ�j 0 S <br /> Masterfile Record Pink <br /> 48-02-034 <br /> rnrinnnt <br />