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USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT <br /> .. <br /> MASTERFILE RECORD 1INFO TION FORM RECEIVED <br /> New EH Pro am at Existing Facilif w EH Program and New Factli MAY 3 0 2013 <br /> a ' 't ID o ram Record,ID,,_ 5370D SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> Facility Address HEALTH DEPARTMENT <br /> (Please Check the appropriate description and specify Le, )of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> O Restaurant: Seating Capacity Square Footage Food Handlers Course re uired:. YEs❑ No D <br /> 0 Commissary 0 Dry storage only 0 with Food Preparation ON'triding Machines—Number of Units <br /> 0 Retail Market--Square footage 0 with Moat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> 0 Mobile Food Vehicle--Make Vehicle Type Color — <br /> Registration# License# Sticker# <br /> 0 MobileFo�Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 0 Ternpor*ry Food Facility---.Dates of operation from to 0 Ice Plant <br /> El Special$vent —Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser-»Number of Containers in Multi-head Unit <br /> �.y CUPA 0 State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' � <br /> 0 hazardous Waste Generaior,�--- Tons Generated Per Year ©Recycle/Exempt System(2299) <br /> 0 CRT Offsite handlers(221 B) 0 Silver Only(2222) 0 Appliance Recyolers(2217) <br /> Tiered Permitting Facility 0 Conditionally Authorized(CA) 0 Conditionally Exempt(CE) <br /> 0 Pwdt By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> 0 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 /> 0 IioteUMotel Number of Units G Jail or Exempt Institution---dumber of Units <br /> Employee Housing(2700)Use EmOloyeo j oMdxZ&gbgr Camp Anaftcallon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJEt ION CONTROL(3000) <br /> •0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site• 0 NPL/SEP Cleanup Site O UIC site <br /> 0 Abandoned HW Site 0 non•NPU/SEP Cleanup Site 0 RWQCB Cleanup Site 1O'Nater Quality Remediation Site'' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of poolslSpas at Facility. ❑P901 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing'Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 0 Poultry Farm Maximum numbor of birds 0 Kennel <br /> TATTOO.BODY PIERCING SM <br /> PERMANENT COSMETIC PROGRAM(4100) <br /> JgTattooing ) � a 0 Body Piercing(4120) 0 Permanent Cosmetics(4122) <br /> M0UiD WASTE .(4200) <br /> 0 Pumper Vehklc—Registration# License# Capacity Vehicle•# <br /> 0 Pamper Yard . 0 Package Treatment Piant• 0 Chemical Toilets—Number of Units_ <br /> SOLID WASTE PROGRW(4400) <br /> 0 Landfill [3 Transfer Station 0 Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> 0 Waste Tire Facility 0 Compost Facility 0 Pr"ess/Recycie Facility 0 CIALandiill Site <br /> 0 Refuse Vehicles--Number of Units 17 Dum dws>20 cu yd--Number of Units 0 Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 0 Primary Care O Acute Care 0 Skilled Nursing 0 Large Generator LD small Generator ❑Limited hauler <br /> 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility----0 2-10—E3 11-60—0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePICSJUM464?-003 Blue AM Llegaden Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT�o� _-___ FEE 4 A90 13 Surcharge FFE 13 Other FEE .....,,__ <br /> INSPECMIt.AMK611. PERMIT VALID to — 7 0 Food handler <br /> [l Check a AMOUNT PDate INVOICE# , <br /> 111 Date <br /> YIEWF.i>6Y .4.CCOUNTINOOFFICE _ <br />