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SAN JOAQUIN COUNTY EN'4i.,,ONMENTAL HEALTH DEPARTAI,,4T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Proat ExisfiM Facility ❑New Eli ProRM and New Facility <br /> Facilit II) l v LA Program Record ID C—D V O 34 4S-E <br /> Facility Address 5- t E' E <br /> (Please Check the appropriate description and specify size number of units and Rertinent information.) <br /> FOOD PItOG M(1640) <br /> ❑Restaurant: Seating Capacity Square Footage Food Iiandiers Course required: Yes❑ Nv ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑3'eading Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prelmckaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Malec 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 /> El Grade A Dairy ❑Grade B Dairy 13 Milk Dispenser Number of Containers in Multi-Bead Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> 11AZARDOUS WASTE PROGRAM(.2200)' 4 <br /> [I fazardous Waste Generator- Tans Generated Per Year ❑Recycle I Exempt System(7299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(x222) ❑ 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 M' PROGRAM(2300)Use UST A and B torts <br /> HOU5ING PiZDGRAM(2400) <br /> ❑HoteMAotel Number of Um ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2740)Use F.mployee IfausraP/Xabor Camp AjT ration Form <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> SITE MITIGATION(2940) <br /> ❑Environmental Assessment 13UST-CAPSite 11Local IfNV Cleanup Site. 13 NPLISEP Cleanup Site ❑U1C site <br /> ❑Abandoned IIW Site ❑non-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ P901 ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Kennel <br /> [I Poultry Poultry Farm Maximuriumber of birds <br /> TATTOO DO PIERCING PERMATIENT COSMETIC PROGRAM(4 100) 11 1'erruanent Cosmetics(4122) <br /> ❑Tattooing(412 1) ❑Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# Capacity <br /> [I pumper Yard El Package Treatment I'lant E3 Clieinical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑Slud elAsh Site <br /> 0 Landfill ❑Transfer Station El Ag I Cannery Waste Site g <br /> ❑ ProcesslRe cle Facility [I CIA Landfill Site <br /> ❑Waste Tire Facility ❑ Compost Facility cY <br /> E] Dumpsters>2(1 cuyd d Number of Units ❑ Farm/Raacb Cleanup Site <br /> ❑Refuse Vehicles--Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ L€mited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—_[] 2-10 ❑ 11-60_0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use pIl'S EIID 46-02403 Btue Application Form <br /> EMERGENCY NOTIFICATION FORTHI$FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON f>ay Ph Night Ph <br /> PROGItA I ELEMENT <br /> ( S FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# O PF Mir VALID to ❑Food Handler_ <br /> 11 �g x AMOUNT PAID �( Date INVOICE# <br /> Q <br /> '1� <br /> Cash VIEWEDDY <br /> AccougnNo OMCE Date l <br /> %7 .te&te Record Pink <br />