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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br />ivIASTERFILE R `RD INFORAIATION FORINI <br />❑ New EH Pro ram at Existin Facility -1!1New EH Pro ram and New Facility <br />Facilitv ID Program Record ID /_iL C11, _5.1 y �) (I�'' <br />Facility Address 0-75 I ' 7— s t <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacit} Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage o-.;: ❑ 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 4 License # Sticker # <br />❑ Temporary Food Facility-----Da:es of operation from to ❑ Ice Plant <br />❑ Special Event --Dates of operat:o- 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 / Exempt System (2299) <br />❑ CRT Offsite Handler- (221 S) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting FacilitN--------- — ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Ilazardous Waste <br />❑ ABOVEGROUND STORK -%GE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STOR:kGE TA -SK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of L; ::s ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Emploi ee HousinglLabor Camp Application Foran <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 n.:trtber of birds _ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100 <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200 i <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 ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of L'nits ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4:00) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinan' Clinic ❑ Common Storage Facility ----- 112-10 ------- ❑ 11 - 60 ------ El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVSEHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT FEE tR ElSurcharge FEE ElOther FEE <br />INSPECTOR # PER.',tIT VALID to ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />1:1 Cash REVIEWED E; 1' ACCOUNTING OFFICE -'- Date vS <br />48-02-034 Masterfile Record Pink <br />11118103 <br />