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t <br /> SAN J'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility U9 New EIi Program and New Facility <br /> Facilit •IDD��l �� Pro ram Record ID 00.5.3 <br /> Facility Address qi h)0P, ( A g533v <br /> (Please Check the appropriate description and specify size,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 ❑Fending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vchicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ElTemporary Food Facility—Dates of operation from to El Icc Plant <br /> 11 Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(20}0) <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)' d <br /> ❑hazardous Waste Generator.— Tons Generated Per Year ❑Recycle I 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 /> ❑Pennit-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 B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Errrployee Il'ousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROV3000) <br /> ❑Environmental Assessment ❑ UST-CAP Site ❑Local IIW Cleanup Site, ❑NPLISEP Cleanup Site ❑ UIC Site <br /> ❑Abandoned MY Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑ 'Yater 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 El lienncl <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Per-maneut 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 /> 11 Landfill 11 Transfer Station 11 Ag I Cannery Waste Site 11 Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑Process[Recycle Facility ❑ CIA-Landfill Site <br /> Refuse Vehicles—Number of Units ❑Dumpsfers>20 eu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator C] Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-[] 2-10 ❑ 11-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UscPIVSEHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATIO14 FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROCR.AM1IELEItmNIT—1�1'14 v_ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# .1402�_ _ PERMIT VALID to ❑ Food Handler <br /> — <br /> ❑ Chcck 0 Amowr PA(I) Date 7 Q INVOICE# ---- --- <br /> ❑ Cash ILEVIEwED BY (��r COL _AccouNTndO OFFICE l -=Date <br />