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AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> UaNewE,:HProrramatExistiu Facility ❑New EH Pro and New Facility <br /> ilit ID C Pro ram Record ID, < `' <br /> I acility Address <br /> (Please Check the appropriate description and specify Ej.M number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restauraut: Seating Capacity Square Footage Food handlers Course required: YES❑ NO❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Veuding 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# Slicker# <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 Dalry ❑ Grade B Dairy ❑ Milk Dispenser—Numbu oCContainers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)- 1 <br /> ❑hazardous Waste Generator Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(22is) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unitt-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST - <br /> '1 UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employ«Housing(2700)UseF I*yeelroasinellAbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ USI'-CAP Site ❑ Local HW Cleanup Site_ ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑non-NPIISEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH 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 /> El 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 /> ❑ PumperVehicle—Registration# License# Capacity Vehicle - <br /> ❑ PumperYard ❑Package Treatment Plant- ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Laudrill ❑ Transfer Station ❑ Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑CIALandfillSite <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—❑ 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIS F.IID 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR Tins FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON r) Day Ph Night Ph <br /> PROGRAM ELLEI%JENT Z if - FEE ❑ Surcharge FEE ❑ Other FEF, <br /> INSPECTOR#L /J7 /0 <' PERMITVALID to <br /> 11 Food Handler <br /> ❑ Check AMOUNT PAID Date INVOICE# <br /> El cash REVIEWED BY AccouNnNG OFFICE ��-�� Date <br /> -- --- M�oMi•Riv-nrA Piny <br />