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SAN JOAQUIN COU E ONMENTAL HEALTH D R .NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facty ❑New EH Program and New Facility <br /> Facility ID rA 0011 Oil Program Record ID <br /> Facility Addressd� � - <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 11 <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 11 Ice Plant <br /> ❑ Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM(2000) <br /> El Grade A Dairy El Grade B Dairy 11 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 Offsgte Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility------------------El 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 CSTA and B(ortn <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> El Hotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units <br /> Employee housing(2700) Use Employee flousinLglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number oI'Pools/Spas at Facility El Pool 11 Spa <br /> [1 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm -------Maximum number ol'birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(412 1) El Body Piercing(4120) El Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle -Registration 4 License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ <br /> ❑ A /Canner Waste Site Sludge/Ash Site <br /> El Landfill El Transfer Station g Y <br /> $Waste'1'ire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br /> ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--NLlmbel"of Units ___ ❑ Dumpsters>20 cu yd----Number of Units____ ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care F-1SkilledNursing 11 Large Generator ❑ Small Generator 11 Limited Hauler <br /> 1:1 Transfer Station El Veterinary Clinic ❑ Common Storage Facility----El 2- 10-- ❑ 11 60 - ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-00.3 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM El.l?11EN'I' V_7Lf 0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> IwstIECTo►:# CO&O <br /> PL:RMff VALID to ❑ Food Handler <br /> ❑ Check# A>ITOUNT PAID Date INVOICE# <br /> 1:1 Cash REVIEWED BY0 �Q 7 dr ACCOUNTING OFFICE Date /oil 1,0 S <br /> Masterfile Record Pink <br /> 45-0?-034 <br /> 10.'6'_UO3 <br />