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SAN JOAQUIN COUNTY E r ONMENTAL HEALTH DEPAR _NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Proeram at Existing Facility ❑New EH Pro ram and New Facility <br /> Facilit ID Program RecordID �—'o �v/C) <br /> Facility Address 30131 <br /> (Please Check the appropriate description and speci size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 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-----%,take 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 /> 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 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:QST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use LISTA and B(amts <br /> HOUSING PROGRAM(2400) <br /> ❑ llotel/Motel-------Numbcr of Units ❑ Jail or Exempt Institution-------Number of Units <br /> EmploNee(lousing(2700) Use Employee HousinglLabor 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 Facilit% 11 Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry Farm -------%la.ximum number ofbirds <br /> El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) ?` <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> FJ Waste"fire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ lieruse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number ol'Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 1:1Primary Care El Acute Care El Skilled Nursing ❑ Large Generator 1:1 Small Generator 11 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PfVS EHD 46-02-003 Blue Application Form <br /> n, <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON _ pb <br /> Day Ph 5,3L - q:,2-, Night Ph <br /> PROGRAM ELEMENT I 1 7 1 V FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# Qv 6 L PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AaIO,nUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY �j" ACCOUNTING OFFICE Date 0 b <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/b/20�i3 <br />