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SAN J"OAQUIN COUNTY ENVIRONM-ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> ELL <br /> w EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilif ID t7�(S Pro ram Record ID (� $"3 <br /> Facility Address 1 a� <br /> (Please Check the appropriate description and specify size,number of unI s 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 ❑Veadiag 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 Dispeaser—Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS'NVASTE PROGRAM(2200)' f <br /> ❑hazardous Waste Generator..- Tons Generated Per Year ❑Recycle I 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 /> ❑Pen-nit-By-Rule Fixed Unit ❑Permit-By Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AS T <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenlotel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee FlousinelLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site 11 Local MV Cleanup Site, [INPLISEP Cleanup Site 11 UIC Site <br /> ❑Abandoned HW Site ❑ non-NPL ISEP Cleanup Site ❑RWQCB Cleanup Site ❑`Vater Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. 111`901 ❑ Spa ❑Out of Service Pool/Spa ❑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 /> b4Tsttooiag(441 +r e4tl U ❑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 ❑PrecesslRecycle Facility ❑ CIA�LandfilI Site <br /> �p <br /> ❑Refuse Vehicles—Number of Units ®Dumpsfers>20 cu yd—Number of Units ❑Far l WOM 1 Site <br /> MEDICAL WASTE PROGRAM(4500) 11''�+HH�(��►�� ��nn <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator Rg(itCti YdWier <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60--�{1��>�O�geylkiors <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVSEMD 46-02-003 Blue Applicadarl Form <br /> SAN JOAQUIN COUNTY <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM ENVIROMENTAL <br /> CONTACT PERSON Day Ph Night Ph HEALTH DEPARTMENT <br /> PROGFANIELEMEVTZlI�_ FEE4 11 ❑ Surcharge FEE - ❑ Other FEE <br /> INSPECTOR#f PERMIT VALID I'S to 6--30-It) ❑ Food Handler_ <br /> CJ c heel I AMOUNT P AID _ Date�� 11NOICE# <br /> _ri�I;\'IEWF.liBY _v_ — ___ A%COVNTINGC}FFICE _ _��/C,/_Date -7,,���---'T--,- ,_ <br />