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[SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at Existin Facility ❑New EH Program and New Facility <br /> Facilit H) O � Program Record ID Rc)53w 7f0 <br /> Facility Addressl 5 20 N 61. DO"Lo STT <br /> (Please Check the appropriate description and specify s'Iz number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs❑ No❑ <br /> ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only <br /> i ❑ 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 /> [3 Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> [3 Special Event —Dates of operation from - to 11 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dalry ❑Grade B Dairy ❑Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' i <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Onsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) - <br /> ❑Pemrit-By-Rule Fixed Unit 0 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 /> ❑Hotel/Motel Number of Units Jail or Exempt Institution—Number of Units <br /> EmployeeMusing(2700)Use EmployeeHeEEi bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. L1 NPIISEP Cleanup Site ❑UCC Site <br /> ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility []pool ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑Kennel <br /> ❑Poultry Farm—Maximum number of birds - <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑pumper Vehicle—Registration# License# Capacity <br /> 13 Pumper Yard ❑Package Treatment Plant" ❑Chemical Toilets—Number ofUnits <br /> SOLID WASTE PROGRAM(4400) <br /> te <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ CIA LandSludgdAsll Si <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 ❑ FarndRanch Cleanup Site - <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator D Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑VeterinaryClinic ❑Common Storage Facility--[] 2-10—❑ !1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePN'SEHD 46-02-003 BlaeApplicadon Form _ <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE '. ❑ Other FEE <br /> ❑Food Handler <br /> INSPECCOR# PERMITVALtD to <br /> ❑ CcekR AMOUNT PAID Date INVOICE# <br /> h <br /> ❑ Cash REviEwED'BY ACCOUNTING OFFICE Date <br /> Recn,d Pink <br />