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SARJOAQUIN COUNTY IRONMENTAL HEALTH DEPAR <br /> NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> IJ New EH Program at Existing Facilitygw EH Progr m and New Facility <br /> FacilityID -- Pro ram R cord ID <br /> Facility Address r 1 - (�-10 <br /> (Please check the appropriate description and specify size, number of units andel a ent information.) , <br /> FOOD PROGRAM(1600) v <br /> ❑ Restaurant: Seating Capacity_ Square Footage Foo Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑V nding Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Mul iple 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❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispepser- umber pfContainers in Multi-Head Unit <br /> + d a, l w^a��sc piton l 09 <br /> CUPA Ela [GEx ��('U <br /> azardous Materials Business Plan(1900) Number of chemicals: <br /> CaIARP Program Program 1 Facility ❑ Program 2 Facility d Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)---------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233, 2234,2235, 2 37) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exen pt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION COI,TROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ElUIC Site <br /> ❑ Abandoned HW Site 11 non-NPL/SEP Cleanup Site 11RWQCB Clea up Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of ervice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm-------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (41I 0) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> El Pumper VehicleRegistration# License# apacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic I Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Si e ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Fac <br /> El Refuse Vehicles(#orumts) lity 11 CIA Landfill Site <br /> ElumP Dsters>20 cu yd (u of Units) ElFarm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generato El Small Generator [I Limited Hauler <br /> El Transfer Station El Veterinary Clinic [I Common Storage Facility 2- 10 El11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicata n Form I,C�� <br /> EMERG NCY NOTIFICATI FORTHIS FACILITYAND/OR PROGRAM <br /> CONTACT PERSON \ 1 Night Ph <br /> PROGRAM EL ENT G I FEE ❑ Surcharge F E ❑ Other FEE <br /> INSPECTOR# G•r�SS I PERMIT VALID to ' ❑ Food Handler <br /> ❑ Check 1 AMOUNT PAID Date NVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE ,Dat@ <br /> 48-02-034 _-(�+ �-� 'S ,� �. r,.- MASTERFILE R ORp.I _ f�(l ION PINK <br /> 1/23/13 ( O( o�;t_ CE/Z�i S1bb Jc <br />