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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> il PAYMENT <br /> MASTERFILE RECORD INFORMATION FORM RECEIVED <br /> ew EH Pro at Existiu Facility ❑New EH(Pro and New Facility ��� <br /> Facili h) F O Q C(D Pro rant Record ID q D S 'Z 2011 <br /> ORONME OUNTY <br /> Facility AddressSM <br /> HEk-h1 DEPggI�TNE yr <br /> (Please Check the appropriate description and specify�number of units and Derti nl information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No f <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 ❑ 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) <br /> S <br /> ❑hazardous Waste Generator. Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pernat-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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee IIousing(2700)Use Emplovee HousinglLabor Camp APPRPxrlan Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) . <br /> ❑Environmental Assessment ❑UsT-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPIZEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site ' <br /> RECREATIONAL HEALTH PROGRAM(3600) - <br /> Number of Pools/Spas at Facility ❑Ppol ❑spa ❑Out of Service PoolfSpa ❑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) ❑ 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/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 ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care . ❑Acute Care ❑ Skilled Nursing ❑Large Generator I] Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EffD 40-02-003 Blue Application Form <br /> nn ' EME. <br /> GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT ,.,ON /!tA HAS Day PhSgZ� �70-,'�/� NightPh�!V� <br /> PROGRAMELEMENT FEE 0-6 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �l� VERMIT VALID b 1 1-k \\ - to k ( 3O 412- ❑ Food Handler ry <br /> ❑ Check# AMOUNT PAID ((,. Q� Date to(zl --1 -%P90(� INVOICE# <br /> Cash REVIEWED BY AccouNnNGOFHCE Date (p 22 <br /> aam.nM Mastefile Record Pink <br />