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SAN JOAQUIN COUNTY ONMENTAL HEALTH DEPARTA T <br /> INFORMATION FORM <br /> MASTERFILE ARD <br /> •❑•New EH Pro ram at Existing Facility w EH Program and NeFacility <br /> FacilitI ID Pro ram Record ID ,F_ - <br /> Facility Address 9 A./6} �-'y—, C,, <br /> (Picase Check the appropriate description and specify siz___e number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restauraut: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑'ending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only <br /> ❑Mobile Food Vchicle---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(20W) <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Muld-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator-_-----Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑GRT Offsite Handlers(2218) ❑-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 LISTA and B forms ; <br /> HOUSING PROGRAM(2400) <br /> ❑'Ffotel/Motet Number of Units Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Emplojve IfousigzlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local MV Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned 11W Site ❑non-NPLISEP Cleanup Site 17 RWQCB Cleanup Site ❑Nater Quality Remediation Site ' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number ofPools/Spas at Facility. 13 Pool 11 Spa ❑Out of Service Pool/Spa ❑Natural Bathing'Area. <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO 13ODY 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 ❑Trausfer Station ❑Ag/Cannery Waste Site 11Sludge/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 PR.O.GRAiUI;(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Sidlled Nursing ❑Large Generator D.Small Generator ❑Linrited Mauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage.Facility---[] 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePli'SEFLD 46 02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM / <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMEN-r!� FEE ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR* Ara �6,ki, PERMIT VALID to ❑Food Handler <br /> ❑ eck# ;� AMOUNT PAID Date} - INVOICE# <br /> Cash REVIEWED BY ACCOUNTING OFFICE Date <br />