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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE ORD INFORMATI N FORM <br /> ❑ New EH Pro ram at Existing FacilitX IdNew EI-I Pro ram and New Facilit <br /> Facility ID v v r 5 33 Program Record 11) S 2- <br /> Facility Address <br /> 0 <br /> (Please Check the appropriate description and specify sire,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ 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-----Make Vehicle Type Color <br /> Registration It Liccnse It Sticker# <br /> ❑ Mobile Food Prep Unit--Make VchicIc Type Color <br /> Registration It 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 /> ❑ Crade A Dalry ❑ (;rade Il Dairy ❑ Milk Ulspenscr---Number ol'Containcrs in Multi-I Icad Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> IIA%ARDOUS WASTE, PROGRAM(2200) <br /> ❑ l laz:u•dous Waste Generator-----------=funs Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Ilandlers(2218) ❑ Silver Only(2222) ❑ Appliance Recycicrs(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) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B fornns <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housurr/Labor 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 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--Registralion 11 _ __ License Il _ _ Capacity Vehicle It <br /> ❑ Pumper Yard ❑ I'ncka}a Treatnient Plant ❑ Chen1lcal Toilcts-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <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 Units ❑ Dumpslcrs>20 cu yd ----Number of Units ❑ Farm/Ranch 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-----112- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PFVS EHD 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 147LE o FEE 11Surcharge FEE 11Other FEE <br /> INSPECTOR# PERMITVALID -711 f 0 t-} to bt3Q10S_ ❑ Food Handler <br /> ❑ Check It AMOUNT PAID -:D-- Date t INVOICE# <br /> ❑ Cash Rl:vn:wi:n nv ACCOUNTING OFFICE r Dale Z( t7 <br /> 48-02-034 Masterfile Record Pink <br /> 11/18/03 <br />