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SAN iOAQUIN COUNTY EN'S -ONMENTAL HEALTH DEPART. NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> Ne%N EH Program at ExistingFacility ❑New EH Pro ram;(:I" <br /> ew Facilit <br /> Facility ID t—A I 1�= 2— Program Record ID S5 <br /> Facility Address M- V'I'P.S-f L� <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No 11 <br /> ❑ Commissary 11 Dry storage only El 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 /> El Grade A Dairy C1 Grade B Dairy El Milk Dispenser --Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility------------------El 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 Cornu <br /> HOUSING PROGRAM(2400) <br /> ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Entpimcc Ilousing(2700) Use Employee Housine/Lahor 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 ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number oPools/Spas at Facility ❑ Pool El Spa C3 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> f <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm -------i`la\Inlum numberol'birds 1:1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) x <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Ree cle Facility ❑ CIA Landfill Site <br /> c��1'astc"hire Facility 1:1 Compost Facility Y Y <br /> ❑ Dum sters>20 cu d----Number ol'Units _ ❑ Faun/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--NumbcroflJnits _ __ P� Y <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care El Acute Care El Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler <br /> El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----02- 10-- <br /> El 1 I 60- - -11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P4VS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON S k "PA Tt �y�-' Day Ph Night Ph <br /> PROGRAM ELEMENT U1 -1 y 0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 00 CC O PERMIT VALID to ❑ Food Handler <br /> ❑ Check 4 ALNIOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEss'ED BN' e_ 4 ACCOUNTING OFFICE rid Date <br /> Masterfile Record Pink <br /> 48-02-014 <br /> 10/6/20W <br />