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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORDINFORMATION FORM <br /> ❑New Ell Pro at ExistingFacility ew EH Pm and New Facility <br /> - <br /> AI <br /> y ID Pro ram Record ID 0 2963!5 <br /> Facility Address 2 \ CA 9 32>0 <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 ❑with Food Preparation ❑Fending Machines Number of Units <br /> 13 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 ❑ Iee Plant <br /> ❑Special Event --Dates of operation from to 13Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> 4 CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' i <br /> ❑Hazardous Waste Generator. Tons Generated Per Year 1❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑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 /> ❑Hotd/Motcl Number of Units ❑Jall or Exempt Institution-----dumber of Units <br /> Employee Housing(2700)Use Employee Housix,/La6or Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> -❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPLSEP Cleanup Site ❑RNVQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service Pooi(Spa ❑Natural Bathing Area <br /> VECTOR.COHTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birdsKennei <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) - s <br /> E3 Tattooing(4121) [3 Body Piercing(4120) [3 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 /> ❑L.andfdl ❑Transfer Station ❑Ag(Cannery%Paste Site ❑Sludge(Ash Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycie Facility ❑CIA,Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑Durr&ers>20 cu yd Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑Primary Care ❑Acute Care ❑Sldlled'Nursing ❑Large Generator Q Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-0 2-10 ❑ 1 l-60--❑>60 generators <br /> PUBLIC WATER SYSTEM_PROGRAM(4600)Use PWS EHD 46-02-003 Blue APP6Wdon Form <br /> EMERGE CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPERSON f DayPhz09-8�-aARK NightPh <br /> --Of� <br /> PROGRAM ELEMENT � 5 FEE ❑Surcharge FEB ❑Other FEE <br /> INSPECTOR# PERMIT VALID 2l0 to 2-(3 t o 11 Food Handier <br /> \Sk# AMOUNT PAID 55, D 0 Date �� D INVOICE# l 5q 3 <br /> J W st, * REVIEWED-BY AccouNTING OFFICE Date <br />