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SAN JOAQUIN COUNTY EN' ONMENTAL HEALTH DEPART. rT <br /> MASTERFILE RECORD INFORMATION FOR1I <br /> IiNew EH Program at Existing Facility ❑New EH Program and New Facilit <br /> Facility ID P 0001 C' Program Record ID _� S2(o (c _ <br /> Facility Address - 6? q3(c <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 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 i1'Iarket----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 -intake Vehicle Type Color <br /> Registration# License# Sticker# <br /> El Temporary Food Facility-----Dates of operation from to El lee Plant <br /> C3 Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM (2000) <br /> C3 Grade A Dairy El Grade B Dairy 1:1 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 LISTA errd B forms <br /> HOUSING PROGRAM(2.100) <br /> ❑ Hotel/Motel-------Numbcr of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee llousing(2700) Use Emnlovee HoushwlLnhor Cmnn Annlication 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 IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM,(3600) <br /> Numbcr of Pook/Spas at Facilit% ❑ 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,(4 100) <br /> ❑ Tattooing(1121) ❑ 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 ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> n Waste"fire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Itefuse Vehicles--Number of Units ❑ Rwnpsters>20 cu yd----Number of-Units_ ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> El Primary Care ❑ Acute Care El Skilled Nursing <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----C3 2- 10------- ❑ It -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM,(4600) Use PIVS EHD 46-02-003 Blue Annlication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM. <br /> CONTACT PERSON Day Ph Night Ph <br /> t —� ❑ Surchar a FEE 13 Other FEE <br /> PROGRAM ELEt1EN'1' I I lv FEE g <br /> INSI'EC-IOR# t�'�' � (' PERMff VALID to ❑ Food Handler <br /> 11Check 4 AI•IOUNT PAID Date INVOICE# <br /> 11 Cash REVIEWED 85' T+� ,2[2S j)( ACCOUNTING OFFICE - Date ` �l��<% _ <br /> - Masterfile Record Pink <br /> 48-0'--01J <br /> 10/b/2010 <br />