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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM _ <br /> ❑New EH Program al Existiu Facility &New Ell Program and New Facility <br /> Facility ID 6A-1-)X963 Pro rani Record ID �3 53 3 <br /> Facility Address _-2C)1 e+fnCWC <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food IIandlers Course required: S'l ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ rsitll Food Preparation ❑Vending 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 /> ❑ Temporary Food Facility--Dates of operation from to ❑ Iee Plant <br /> ❑ Special Eveut --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000 <br /> El Milk-Dispenser—Number of Containers in Multi Bead Unit <br /> El Grade A Dairy El Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS 1VASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator---- Tons Generated Per Year ❑ Recycle(Exempt S}'stent(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered I'erntilting 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 o[AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Usc UST A and B(oras <br /> HOUSING PROGRAM(2400) <br /> ❑ hotenlotel Numbcr of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee housing(2700) Use Frrtplopee llousirct'/LaGor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAroumental Assessment ❑ UST-CAP Site ❑ Local I1W Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 1II5'Site ❑ non-NPLISEP Cleanup Site ❑RWQC13 Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑fool ❑ Spa ❑ Out of Senice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm Maximum number of birds 1:1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(4121) 11 Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill IJ Transfer Station ❑Ag I Cannery\Taste Site <br /> ❑ Sludge/Ash Site <br /> \Vast,Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ P.efuse Vehicles--Number of Units ❑ Dumpsters>20 cuyd—Number of Units ❑ Farm/I'.anch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---E] 2- 10 ❑ 11 -60----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Usc P1t,S EHD 46-42-003 Plac Application Form <br /> EMERGENCY NOTIFICATION FOR Tills FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON !� u Day Ph Night Ph <br /> I'ROGtL1Nt ELEMENT —l 1 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPF,CTOR#ac'),C) PERMITVALID to ❑ Food handler <br /> ❑ ch-ck k AMOUNT PAID _ Date INVOICE It I// — <br /> ❑ Cash I EVIEwEDBY ACCOUNTING OFFICE - ==-SG Date <br />