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SAN JOAQUIN COUNTY ENVIRONAIEN'TAL HEALTI1 DEPARTMENT <br /> MASTERFILE RECORD INFOrnIA'TION FORM <br /> New EH Program at Existia Facility ❑New EH Program and New Facility_ <br /> Facilif 'ID - (� 3 Pro �mR �rd 3��qS <br /> FacilityMdt-ess <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 <br /> Fond Handlers Course required:. YEs❑ No <br /> ElCommissary ElDry storage only El with Food Preparation ❑Vending 14iach[nes—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile Food VColor <br /> ehicle--Make Vehicle Type Sticker# <br /> Registration# License# <br /> Type❑ Mobile Food Prep Unit—Make Vehicle T�� Color Sticker# <br /> Registration# License# <br /> ElTemporary Food Facility—Dates of operation from <br /> to El Ice Plant <br /> ❑ Special Event —Dates of operation from <br /> to El Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispeuser—Number of Containers is Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' i <br /> ❑ hazardous Waste Generator.— Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) [1 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 jR forrrcs <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/litotel Number of Units ❑flail or Exempt institution Number of Units <br /> Employee housing(2700)Use FmploreeOorrsinz4abor Camp Applicadarr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmienfal Assessment ®UST-CAI'Site ❑LocalIl1V Cleanup Site• ❑NPLISEP Cleanup Site El Site <br /> ® Abandoned 11WSite ❑ non-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site El 'Yater Quality Remediation Site <br /> RECREATIONAL HEALTH. PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P®ol [I spa El out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ®KennelElPoultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 11Tattooing(4121) ❑Body Piercing(4120) El Permanent Cosmetic(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> El Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill ❑ Transfer Station [I Ag/CanneryWaste Site ® SludgetAslr Site <br /> C t Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑FarmfRaach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care El Acute Care ❑ SkHlcd Nursing ❑ Large Generator El Small Generator El Lin <br /> Mauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--El 2-10 ❑ I1-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Uscf[VSf KB f642-003 B1rreAnptica6cn Form <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY AND€OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph — <br /> _ *-I i <br /> PROGRANIELEmENT lu FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# — PERMITVALID �_ to p �% �(2� ❑ Food hander__ <br /> �I1tOUN'r I'.Al Date 1tIV0ICE It <br /> E.� C'hcck{; --- — <br /> _ ) —� Date <br /> ❑ Cash ---i':EVIENYF.0 BY r (l 4�C0[R:T(N i }FFICL _-- --- <br /> - �-z- -L--� - <br />