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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIYIENT <br /> NIASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility _New EH Program and Netisl��Facility <br /> Facility ID D10 9-00 J S_� Program Record ID <br /> Facility Address 3".� _ E. � ?�� -7 <br /> (Please Check the appropriate description and specify size,Rumbel of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No 11 <br /> ❑ Commissary ❑ Dry storage only 11with Food Preparation ❑Fending 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 ❑ 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 I 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)(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 Fmnloyee HorrsinP/Ubor Camp Appficadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> 11 Environmental Assessment ❑UST-CAP Site 11W Cl <br /> Local IIeanup Site. ElNPLISEP Cleanup Site El UIC Site <br /> ❑ Abandoned TINY Site ❑ non-NPLISEP 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 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(4121) ❑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 /> ❑ Laud"-11 ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ,,Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch 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 PWSEHD 46-02-003 MacAppficarion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGRAM ELEh1ENT/- FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �c�. PERMIT VALID to ❑ Food Handler <br /> ❑ Check# ArtOt)NT PAID _ Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />