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SAN JOAQUIN COUNTY ENVIRONAI,ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RE CORI)-INFORIV4ATION FORM <br /> ❑New EH Program at Existin Facility ❑New EH P/nr�og--ram and New Facility <br /> Facility ID 0, (D -7Pro ram Record ID <br /> facility AddressS - <br /> (Please Check the appropriate description and specify size.number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES El 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 /> ❑ Temporary Food Facility—Dates of operation from = to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy, ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS«'ASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator.=— `Pons Generated Per Year ❑ Recycle f Eacmpt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-lay-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TAMC FACILITY(AST)(2390) Number of AS T <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B{arms <br /> ROUSING PROGRAM(2400) <br /> ❑ Iiotel/14Iote1 Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Ilousiiae(2700)Use Fmplaw dlowsircff/I,abor Camp Appfica(iort Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local MV Cleanup Site' El NPIJSEP Cleanup Site ElUIC Site <br /> ❑ Abandoned IIW Site El ;non-NPLISEP Cleanup Site 13anup <br /> R)VQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEAL'T" 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 Farrar Maximum number of birds ❑Kennel <br /> -rATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4 120) ❑ 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 /> 11 Landfill 1-1TransferStation 11 Ag/Cannery AYaste Site El Sludge/Asla Site <br /> K Waste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA-LandfIllSite <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ FarmIl anch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care 13 Skilled Nursing El Large Generator 0 Small Generator El Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facil-it)•--❑ 2-10 ❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVSEFID 46-02-403 BlueApplica(iort For7n <br /> EMERGENCY NOTIFICATION FOR TKis FACILITY AND/ort PROGRAM <br /> CONTACT PERSON _ Day Ph Night Ph — <br /> PROGR4AI ELENIENT q NLa_ EE ( ❑ Surcharge FEE - ❑ Other FEE _ <br /> INs'FCrOR# _ PERMITVALIDto El Food handler—._ <br /> El AAOUNTP ID ------- CO _ _ ;Date �� hV010E(# <br /> Cash R-EvIEwED By Arno dTING OFFICE 7Z'_ � Date r I --- ---_ <br />