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SAN JOAQUIN COUNTY EN NMENTAL HEALTH DEPARTIOT <br />MASTERFILE RECORD INFORMATION FORM <br />ew EH Program at Existing Facility ❑New EH Program and New Facility <br />Facil-ity ID FA OC% 9'q a Program Record ID 3 8 3 <br />Facility Address 5-0S Ca r �� �ti 1 �� 9d. S t c (<+r� n <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ NO ❑ <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 />El Temporary Food Facility ----- Dates of operation from to El Ice Plant <br />1:1 Special Event -- Dates of operation from to El Produce Stand <br />DAIRY PROGRAM (2000) <br />F-1 Grade A Dairy El Grade B Dairy ❑Milk Dispenser --Number of Containers in Multi -1 lead 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 Flazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (23 90) Number of AST <br />UNDERGROUND STORAGE TANK (US"r) 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 />Employee (lousing (2700) Use Employee Housing/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 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO. BODY PIERCING PERMANENT COSMETIC PROGRAM (4100; <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # <br />❑ Pumper Yard ❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets ------Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care 13 Skilled Nursing ❑ Large Generator ❑Small Generator El Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- ❑ 2 - 10 ------- ❑ 1 I - 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 />PIt0(;l1ANF EI,ENIENT I t1L Ftas _ <br />INSPECTOR # 00 � PERMI'r VALID <br />❑ Check 9 <br />❑ Cash <br />48-02-034 <br />ANIOUNT PAID <br />REVIEWED By Jf V L k4u <br />ShIlr,, <br />❑ Surcharge Fl-;li ❑ Other FILE _ <br />to ❑ Food Handler <br />Date <br />ACCOUNTING OFFICE <br />INVOICE # <br />Date YM516S <br />Masterfile Record Pink <br />