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SAN JOAQUIN COUNTY EN14ENTAL HEALTH DEPART <br /> MASTERFILE PORD INFORMATION FORM <br /> New•EH Program at Existing Facility . ew EH Program and New Facility <br /> Facility ID a Pro ram Record ID j�53 <br /> Facility Address 9�� Clo,Ah( All T/ t�,! Cj . q.5 j�(D <br /> (Please.Check the appropriate description and specify s_g number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Fending 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 /> 13 Temporary Food Facility----.Dates of operation from = to ❑ Ice Plant <br /> ❑Special Event --Dates of operation from to ❑Produce Stand <br /> -s = <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 /> t <br /> ❑Ilazardous Waste Generator. Tons Generated Per Year _ 13 Recycle 1 Exempt System(2299) <br /> ❑CRT Offsite Handlers(221s) ❑-Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Pemnit-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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> 13'Ilotel/Motel Number of Units ❑Jail or Exempt Institution Numbcu of Units <br /> Employee housing(2700)Use Employee Ifousin--/Labor CamApy(icatien Fore <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION 90NTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPUSEP Cleanup Site ❑UIC Site <br /> t: <br /> ❑Abandoned HAY Site ❑non-NPIJSEP Cleanup Site ❑RNYQCB Cleanup Site •❑lVater Quality Remediation Site ¢` <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Nurnber of Pools/S <br /> pas at Facility. ❑Poo! El spa 13 out of Service Pool/Spa 13 Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds <br /> 13 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 9f Units <br /> SOLID WASTE PROGRAM(4460) <br /> 1:7 Landfill ❑Transfer Station ❑Ag/Cannery\Waste Site ❑Sludge/Ash Site <br /> 13 Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility 13 CIA-Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PRO.GRAM,(4500) <br /> ❑ Primary Care ❑Acute Care 13Sldlled•Nursing [3 Large Generator 13,Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑.Veterinary Clinic ❑Common Storage Facility--❑2-l0 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use f W'SBHD (142403 Blue Application Fore <br /> E ERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph �• Night Ph lM1L <br /> PROGRAM ELEMENT FEE ❑Surcharge FEE". . ❑ Other FEE <br /> INSPECTOR# PERMIT VALID . to <br /> 13 Food Handler <br /> ❑ Ci�eck# ) AMOUNT PQI)D Date j INVOICE# <br /> Cash REVIEWEO-BY AccoumwG OFFICE Date x �, <br />