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SAN JOAQUIN COUNTY ENVIRONME,NTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM CONMENTIAL <br /> ❑New EIl Program at Existing Facility []New Eli Program and New Facility <br /> FacilityID 17�a, �� Pro ram Record ID <br /> Facility AddresS so- C). Num Ln <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 11with 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 /> 11 Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> ❑ Special Event —Dates of operation from to El Produce-Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Muld-Head Unit <br /> GUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <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) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenjotel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Eaeployee housing(2700)Use Fmployee ffoasinelLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAF Site ❑Local HSV Cleauup Site. 11NPLISEP Cleanup Site 11UIC Site <br /> 11 Abandoned 11W Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility- 11 P901 11 spa [.I Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 17 Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> 11 Pumper Yard ❑Package Treatment Plant- ® Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill E] Transfer Station 11 Ag/Cannery Waste Site 11 Siudge/Ash Site <br /> ❑'Waste Tire Facility ❑ Compost Facility 17 Process/Recycle 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 kSk1lled-Nurs!,g 11 Large Generator Small Generator ❑Limited hauler <br /> El Transfer Station El Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ i l-60--E]>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePIVSETD 46-02-003 BlrreAnplicatiorz Form <br /> EMERGENCY NOTIFICATION FOR TPAs FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR4htELENIU,T _ FEE 03 ❑ Surcharge FEE'. ❑ Other FEE _ <br /> INSPF_C['OR# ��� PEFMIT VALID_(!� � � t0 HA-U1 <br /> ❑ Food Handler_ <br /> �1 Chcck f' gy�T.�f��OUI IT 1'Aq t e L � — Date INVOICE# <br /> ❑ Cash 1tiiViE�'IEDIIY V� 3 a, ACCOUNTING'JFFICE Date 3 Zy <br /> .—� <br />