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� r <br /> SAN•JOAQUTIN COUNTY ENVIRONNI.ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID —Program Record ID <br /> Facility Address �iy is/l�, �,�- A�� G <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 El No ❑ <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Fending Machines—Number of Units <br /> ElRetail 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 ❑ 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-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <br /> ❑hazardous`Paste Generator.-- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2216) ❑ 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) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/lltotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700) Use Fmplayee IfousinZILabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑Local HW Cleanup Site, ElNPLISEP Cleanup Site L1UIC Site <br /> ❑ Abandoned HAV Site ❑ Cleanup non-NPIJSEP Cleanup Site ❑RWQCB CleSite ❑Nater 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 /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plaut ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ElTransfer Station ❑Ag/Cannery Waste Site El Sludge/Ash Site <br /> ['l�['Waste Tire Facility 11 Compost Facility I.:] ProcesslRecycle Facility El CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Generator [1 Limited Hauler <br /> lTransfer Station El Veterinary Clinic El Common Storage Facility—E) 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePIVSEHD 46-02-003 BlueApplica(ion Form <br /> EMERGENCY 140TIFICATION FOR TRIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 4/ 7 FIEE ❑ Surcharge FEE ❑ OlherFEE — <br /> INsrecroR# -- —.2- — PERhtITVALIO_--- to El Food Handler_ <br /> ❑ check t,_ Amourrr RkII) (�1 _ Date ITIVOICL/{ — -- - --- <br /> El Cash R-EVIEWED BY Ai COUClTIT.G OFFICE — Date 7 r 1 _- <br />