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SAN JOAQUIN COUNTY ENV jNMENTAL HEALTH DEPARTN T <br /> MASTERFILE RECORD INFORMATION FORM <br /> w EH Program at Existing Facility ❑New EH Program and New Facility <br /> AD ' <br /> Ip F � �S L( Program Record ID Q ��o� ,� 7 L—,I �� <br /> Faculty—TNeN�l � C�� <br /> ---�--OC) `� — --- <br /> Facility Address l�10 NczeI "U ' At c'-e �t20S�3Y3a <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 Food Handlers Course required: Yes El No El <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# License# Sticker# <br /> ❑ Mobile Food Prep Unit -Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> Ell Temporary Food Facility-----Dates of operation from to El 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/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 USTA and B fornls <br /> HOUSING PROGRAM.(2400) <br /> ❑ Ilotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee(lousing(2700) Use Emplovee!/ou,sint,/Labor Canin 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 /> El Poultry Farm -------Maximum number of birds El Kennel <br /> TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM.(4100) <br /> ❑ Tattooing(412 1) ❑ 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 /> ❑ Landfill 1:1 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> 34aste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM.(4500) <br /> El Primary Care ❑ Acute Care 13 Skilled Nursing 13 Large Generator ❑ Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----C3 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM.(4600) Use PWS EHD 46-02-003 BlueAvnlication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM. <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRARI ELEMENT L1-1`40 + Li-?3c' FEE ❑ Surcharge FEE ❑ Other FETE <br /> INSPECTOR# C,(.(^ ' PERMIT VALID to ❑ Food Handler <br /> ❑ Chcck# AMOUNT PAID Date INVOICE## <br /> /as�0� <br /> 11 Cash REVIEWED l3Y ACCOUNTING OFFICE Date <br /> ��lt��� ---- ----------- =-- <br /> Masterfilc Rccord Pink <br /> 48-02-034 <br /> 10/6/10(11 <br />