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r <br /> SAN JOAQUIN COUNTY FNVIRONI%IENTAL HEALTH DEPARTMENT <br /> l4IASTERFILE RECORD INFORMATION FORM <br /> X New EH Program at Existing Facility ❑New Ell Program and New Facility_ <br /> Facility ID JEAQ0Pro ram Record ID <br /> Facility Address CLQ �re12'1 �` <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 IIandlers Course required: YES ❑ No ❑ <br /> ❑ Commissary11Dry storage only ❑ with Food Preparation ❑Vending Machiues—Number of Units <br /> ElRetail 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 /> [I 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 /> ❑ 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) t <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 /> ❑Pcn-nit-By-Rule Fixed Unit ❑Pernut-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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenfotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Ffnpfoyee HousirtzlLabor Camp Appficafiou Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑ Local HW Cleanup Site, ElNPLISEP Cleanup Site 11UIC Site <br /> ElAbandoned 111V Site 11non-NPLISEP Cleanup Site 13RWQC13 Cleanup CleSite ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number ofPools/Spas at Facility El Pool ❑ Spa ❑ Out of Scrz�ice Pool/Spa 13 Natural Balding Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds 11 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—Registration# License# Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill 11 Transfer Station 11 Ag/Cannery Waste Site <br /> F-1 Sludbe/Ash Site <br /> M\Vaste Tire Facility ❑ Compost Facility ❑Process/Recycle facility ❑ CIA,Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11Primary Care El Acute Care 11 Skilled Nursing 11 Large Generator 11 Small Generator 11 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-11 2-10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHLS FWD 46-02-003 flue Applica(iorc Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> /� <br /> PROGRAM ELEMENT 77�C FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �(� PEKMITVALID . to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date o INVOICE# _ <br /> ❑ Cash I:EVIEwF_D BY ACCOUNTING OFFICE _�_�fj` Date; J/J <br />