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r SAN JOAQUIN COUNTE ONME <br /> Y NTAL HEALTHDEPART!..—iqT ?WMENT <br /> l MASTERFILE RECORD INFORMATION FORM RECEIVED <br /> ❑New EH Program at Existin Facility ❑New EH Program andyNew Facility MAR <br /> g 2012 <br /> FacilityID <br /> Pro ram Record ID 53 0 / <br /> SPIN}OAb MIL <br /> N�TM oON�`R <br /> FacilityAddrems 4J It--00 <br /> (Please Check the appropriate description and specify EjZ number of units an pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating Capacity Square Footage Food Handlers Course required: Yrs❑ 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 11 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)" t <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 B) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Pemtit-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 farms <br /> HOUSING PROGRAM(2400) _ - <br /> ❑Hotel/Motel—Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Fmplovee 71pusinglLabor Camp Application Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IiW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pgol ❑Spa El Out of Service Pool/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) El 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 /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ask 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 ❑FanWRanch 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--[] 2-10—El 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS END 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACrPERSON TkCl—a/1" Day Ph Z-7,T- t�9 2 2 Night Ph <br /> PROGRAM ELEMENT - FEE I I( Io-69 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID J)o 1 17— t0 K ❑Food Handler <br /> ❑ Check# AmOUNT�PAID 11 Ie . CC) Date 3/V(ZZ INVOICE# <br /> Cash REViEWEDBY 60 /19 TI <br /> ACCOUNNG OFFICE Date .3/2/12--- <br /> ,. , , Made&.le Record Pink <br />