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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTLI <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility jg�ew EH Program and New <br />Facility ID f r f)V i -S. <br />Program Record I � , 410 �P <br />Al! G 2 q 2007 <br />ENViP10NARcNT VICES H <br />�g PERMITISER <br />Facility Address �;2v6 <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 ❑Vending 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 />13Temporary Food Facility --•Dates of operation from to <br />❑ Special Event -Dates of operation from to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy, ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi -Head Unit <br />-.t CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle I Exempt System (2299) <br />❑ CRT 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 UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housing -/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site • ❑ NPL/SEP Cleanup Site ❑ UTC Site <br />❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site 1 ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility . ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR.CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) WBody Piercing (4120) ❑ <br />Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # Capacity <br />Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA•Landfill Site <br />❑ Refuse Vehicles -Number of Units ❑ Dumpsfers > 20 cu yd —Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ' ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—[] 2 -10 <br />❑ 11- 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWSEHD46-02-003 Blue ApplicationFor•m <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON V r4 r r 'P c Day P /- <br />Night Ph <br />PROGRAMELENIENr ff12-0 412--t C��- ❑ Surchar aFE/E <br />Othe FEE' � R — <br />I — <br />! <br />INSPECTOR# G��Sy PERIJMITVALID-1 / � <br />� <br />10 Foo d, ler <br />i t <br />11 Check # AMOUNT PAID <br />INVOICE # <br />❑ Cash REVIEWED BY j `3 Z% Z - ACCOUNTING OFFICE '� <br />Date ? f7 7 <br />