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• <br /> SAN JOAQUfN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> ' New EH Program at Exisfin Facility []New EH Program and New Facility <br /> Facilif ID <br /> Program Record ID S3 6 <br /> Facility Address tqnm o tc�n s <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ElRestaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No❑ <br /> ❑ Commissary El Dry storage only El with Food Preparation ❑h'endiag Machines—Number ofUnits <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 11 lee Plant <br /> ❑ Special EYeat —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 /> HAZARDOUS WASTE PROGRAM(2200)' { <br /> ❑hazardous Waste Generator. =— Tons Generited Per Year Ll Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(221 s) ❑ 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(LIST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Rotenlotel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee Ilousing(27 00)Use EmployeeFfousine/Labor Camp Application Foran <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Enviroameatal Assessment ❑UST-CAF Site ❑Local IIEV Cleanup Site. ❑NPLISEP Cleanup Site ElUIC Site <br /> 11 Abandoned I1W Site ❑non-NPL{SEP Cleanup Site ❑RWQCB Cleanup Site "D Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Plumber of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service PoollSpa ❑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) 11 Body Piercing(4120) ® Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 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 13 Transfer Station 11 Ag{Cannery Waste Site 11 Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process[Recycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑FarmlRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care 11 Acute Care Skilled Nursing 11 Large Generator 0 Small Generator ❑Limited Mauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PJVS.EKD 46-02-003 BlueApp{ication Form <br /> EMERGENCY NOTIFICATION FOR Tips FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_ Day Ph Night Ph <br /> PROC;rwtELEnIErrr y� FEE �� � ❑ Surcharge FEE ❑ Other FEE — <br /> INSPECroR# 2Q PEP.MIT VALID—1�� to X02��1 11 Food Handler_ p <br /> 1.1 Checkf _ AMOUNTI 6.ID - j��Jate IPIVOICE# <br /> ❑ Cash REVIEWED BY AccouNTim;OFFICE _ �— —Date <br />