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USAN JOAQUIN COUNTY L� IRONMENTAL HEALTH DEPAR...4ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID � 1 �-L Program Record I© $�L` <br /> Facility Address <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course reguired: Yes '❑ 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-Head Unit <br /> CUPA ❑ State Facility Surcharge (2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator--»-------Tons Generated Per Year ❑ RecyclelExempt System(2299) <br /> CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ it-By-Rule Household Hazardous Waste <br /> �IABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of ASTOU UNDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use UST A ands <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing(2700) Use Employee Housin ✓Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of PoolslSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics (4122) <br /> LIQUID WASTE PROGRAM (4200) <br /> El Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(it�,f Un,ts) ❑ Dumpsters > 20 cu yd (a or units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care [I Acute Care El Skilled Nursing El Large Generator El Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application f=orm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT -Z X 4[�_ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED By ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11115;!77 <br />