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J <br /> T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT <br /> I MASTERFILE RECORD INFORMATION FORM <br /> I New EH Program at Existing Facility MNew EH Program and New Facility <br /> Facility ID A C 1� 7-(,4 1-L Program Record ID PACS <br /> Facility Address aVF Rq SCANA fF Fssulo n:j LA <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 ❑Vending Machines—Number of Units <br /> ❑ Retail 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 /> ❑ 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 /> IIAZARDOUS WASTE PROGRAM(2200) a <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 /> ❑Permit-By-Rule Fixed Unit ❑ Permit-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 R forms <br /> HOUSING PROGRAM(2400) <br /> ❑ notenlotel Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee housing(2700) Use Fmplopee 11ousinclLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑ Local IIW Cleanup Site. ❑ NPLJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLJSEP 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 Scarce Pooi/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑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 /> ❑ Landoll ❑ Transfer Station ❑ Ag J Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ ProcessJRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch 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)Use PH'S F11D 46-02-003 Blue Application-Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY AND/OR PROGRAM <br /> CONTACT PERSON h <br /> \ gr Day Ph Night P <br /> PROGRAM ELEMEINT L4 y FEE /V ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# a(ga.7- PERMITVALID to [I Food Handler <br /> ❑ Check 9 AMOUNT PAID Date INVOICE# <br /> 0 Cash REVIEWED BY �� 1P}11 ACCOUNTING OFFICE Date Date (d <br />