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s,1 <br /> ! 'SAN JOAQUIN COUNTY&VIRONMENTAL HEALTH DEPAIWENT <br /> MASTERFILi ECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Faclllt <br /> FacilityID C�U { U Z <br /> Program Record ID o23sJ <br /> Facility Address <br /> (Please check the appropriate description and specify size, number of units and pertinent information.} <br /> FOOD PROGRAM(1600) 13 <br /> Square Footage Food Handlers Course required: YES ❑ No <br /> 13 Restaurant: Seating Capacity <br /> ending Machines Number of Units- <br /> ❑ Commissary ❑ Dry storage only ❑ with Food withMeatMarket only ❑ration VMulple Departments P epackaged Goods Only <br /> ❑ Retail Market----Square footage Color <br /> ❑ Mobile Food Vehicle--Make Vehicle Type <br /> # Sticker# <br /> License <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit Make <br /> License# Sticker# <br /> Registration# 13 lee Plant <br /> ❑ Temporary Food Facility--Dates of operation from to <br /> C3 Special Event Dates of operation from <br /> to 13 Produce Stand <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 /> 13 Hazardous Waste Generator------ Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ------------ ❑ Siler Only(2222) <br /> ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous W as e <br /> ,ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use LISTA and_Bforms <br /> HOUSING PROGRAM (2400) <br /> ❑ <br /> ❑ Jail or Exempt Institution----Number of Units <br /> Hotel/Motel-----Number of Units <br /> Employee Housing(2700) Use Em la ee Housin /Labor Cam AggEcation Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13 Environmental Assessment ❑ UST-CAP Site C3 Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa Out of Service PooilSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> ❑ Pumper Vehicle Registration# License# <br /> ❑ Pumper Yard ❑ Package Treatment Plant Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site g <br /> ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/mpers>20 c Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles(#of Univ) ❑ Dumpsters?20 cu yd{#of Units} <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ ing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> Primary Care ❑ Acute Care El Skilled Nurs <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 ❑ a 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITYANDIOR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> PROGRAM:ELEM1�j FEE ❑ Surcharge FEE ❑ Other FEEPERMITVALID to ❑ Food HandlerINSPECTORINVOICE#❑ Check# AMOUNT PAID Date <br /> ❑ CaShBY <br /> ACCOUNTING OFFICE <br /> Date a- /0 1 Q <br /> MASTERFILE RECORD INFORMATION PINK <br /> 48-02-034 <br /> 11115107 <br />