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SAN JOAQUIN COUNTY IJ'NVIRONMENTAD. -HEALTH DEPARTMENT <br /> 1_llASTERFILE I2ECOi2D iNFOR117ATION FORM <br /> ❑New i✓H Program at Existing Facility 3�1cxy:EM Program and New Facility <br /> Facility 1D O C)Ab3 a Mrat rars2 <br /> Record`1D -7 <br /> Facility Address 0 lx oe_t l <br /> (Please Check the appropriate description and specify size,number or 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 I`Iaclines-Number of Units <br /> ❑Retail 1112rfcet—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 /> ❑Temporary Food Facility—Dates of operation from to ❑ Ice I'lant <br /> ❑ Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ lllilk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> IiAzARDOUS WASTE PROGRAIA(2200) , <br /> ❑ Hazardous Waste Cyenerator Tons Generated Per Year ❑Re-cycle I Ilaempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally E:cerrrpt(CE) <br /> ❑Perinit-By-Rule Fixed Unit ❑ Permit-By-Rule HotLsehold Hazardous Waste <br /> ❑ABO 'EGROUND STORAGE TANK FACILIT`z'(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TAN K(UST)FROGRAIA(23 00)Use UST A and B(o Mrs <br /> f LOUSING PROGRAM(2400) <br /> flotenlotel Nurnber of Units ❑ Jailor Exempt Institution Nu_n-rber of Units <br /> E'Mployee Housing(2700) Use F'nployee.ffouslaelfabor Carnp AppfLCadOfr Farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAroameatal Assessment ❑UST-CAP Site ❑focal 11W Cleanup Site. ❑NrLISEP Cleanup Site ❑ UTC Site <br /> ❑ Abandoned llV�'Site ❑non-NPL./SEP Cleanup Site ❑RNYQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3G00) <br /> Number ofPools/Spas at Facility ❑Pool ❑ Spa ❑Out of Ser�d.ce Pool/Spa ❑Natural Bathiag Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING,PERNTANEHT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID VIASTE PROGRAM(4200) <br /> ❑ <br /> Pumper Vehicle–Regisi–tion# License 9 Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Paclkage Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGPAPrI(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> AWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA.Landfill Site <br /> ❑Refuse Vehicles–Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ F'arm/R2?nch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Stilled Nursing El Large Generator ❑ Small Generator ElLimited IIauter <br /> Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- 10---❑ 11_ -60--❑ >60 generators <br /> PUBLIGWATFR SYSTEM PROGRAM(4600) Uscf IfSEfdD f6-02-003 DhicAprlicatforr Far-m <br /> ENIEaGENCY Flo–HFICATIoN Pon-,ms FACILITY AND/on PROGRAM <br /> CONTACT PERSON ' Day Pb !'light Ph <br /> 1'tiOct-AMEf—CMEN L04/0 FEE ❑ SurchorgeFEE ❑ defter FET, <br /> INSPECT OR# CLQ--! PEU11 T VALID to ❑ hood Handlcr <br /> ❑ Checl;Y AIdOtINT 1'AIU Date li1VOICL-# <br /> ❑ t _h I•_ 'rGl';EDr`:' AcCi)u;4T11'G()FFb--E Da IC �_ <br />