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t <br /> SAN JOAQUIN COUNT:'ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD IN'FORMATION FORTH _ <br /> J New Ell Program at ExistingFacility w EI{FrogTam and ,Nc)v Facility <br /> Facility ID" <br /> D �►Qr 0 d,��� Pro ram Record ID �5�> �� <br /> Facility Address Z OI777Zff �teAr <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAP1l(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required: YFs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail 1llarket—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Mahe 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 o_f operation from to ❑ Ice Plant <br /> F] Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Numbcr of Containers in Mufti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS IVASTE PROGRAM(2200) 1 <br /> ❑ hazardous'Waste Generator-- Tons Generated Per Year ❑ Recycle I ETenlpt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pemut-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 Loans <br /> tAOUSING PROGRAM(2400) <br /> ❑ IIotel/Dlotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700) Use Frrrplopee Housitt&Labor Camp Applicaeiorr Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En-,jronmeatal Assessment ❑UST-CAP Site ❑ Local MV Cleanup Site. ElNPL/SEP Cleanup Site ElUIC Site <br /> ❑ Abandoned II)W Site 11non-NPIJSEP Cleanup Site ElRWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of pools/Spas at Facility. ❑ Pool ❑ Spa ❑ Ord of Sen ice.Pool/Spa ❑ Natural BathirigArea <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds El I<cnacl <br /> 'TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑ r,emanent Co.3metics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatmcut Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag t Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle 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 /> ❑ Traasfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-[] 2-10 ❑ I 1 -60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIKSGffD 46-02-003 P>lrcc.Applicadon Forrrr <br /> EMERGENCY NOTIFICATION FOR Irms FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> 111tOGIL01ELEMENI•4171O FEE ❑ Surcharge FEE ❑ Other FEF.. — <br /> INSrFCrOR# [7C�O PEI MIT VALID to ❑ Food Handler <br /> ElC1r_ek AMOUNT PAID Date INvo1C'# <br /> ❑ Cash REVIEWFDBY ACCOUNTINGOFFI(_E <br />