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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR`T'MENT <br /> )1MASTERFILE RECORD INF0101ATION FORM — <br /> ❑New EH Program at Existin Facility 'Erbew Ell Program and New Facility_ <br /> Facilit ,ID "Cro ram Record ID <br /> Facility Address �(e-� 9U - -re G <br /> (Please Check the appropriate description and specify size,number of units and Ce inent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 11 No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel 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 /> ❑ 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-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2.399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> 11 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 /> ❑Perrnit-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(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Ilousing(2700) Usc Fmployee IfousinzlLabor Carrcp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UTC Site <br /> ❑ Abandoned IIW Site ❑ non-NPUSEP Cleanup Site ❑R\VQCB 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 /> VI=CTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(4121) El Body Piercing(4120) El 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 I Cannery Waste Site ❑ Sludge/Ash Site <br /> )Waste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ FarmII32nch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care IJ Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited IIauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- 10 ❑ I1 -60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Pffl, 1FHD d6-02-003 Blue Applica6orz Form <br /> (EMERGENCY NOTIFICATION FOR This FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Pb <br /> PROGRAM ELEMENT /7/Z�?l© FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID _ to _ ❑ Food IIandler <br /> ❑ Geek h AMOUNT PAID Date INVOICI:ft rr-- <br /> ❑ Cash RT.vtcwr[>nY_ — Ar-couNriNc OFFICE__ ----- Date <br />