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SAN JOAQUIN COUNTY ENVIRONMENTAL I;EALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New Ell Pro ram at Existing Facility ❑New LH Pro and New Facilit <br /> /.. Z�ri <br /> Facility ID <br /> Pro ram Record ID D <br /> Facility Address nNiM & rl <br /> (Please Check the appropriate deseripGon and specify gZ number of units and Pcrtiuevt information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Deparurrents ❑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 /> 11Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> [3 Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dalry ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ` CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200)- r <br /> ❑ hazardous Waste Generator. Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Reeyelers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pcmvt-By-Rule Fixed Unit Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of ASP - <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B fo s <br /> HOUSING PROGRAM(2400) - <br /> ❑ hotel/Motcl—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Houstag(2700)Use Fmvlopee ffaasip¢lLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UTC Site <br /> ❑ Abandoned 11W Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECRFATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa ❑Out of Service P"I/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO.13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ 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/Ask Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch 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-I o—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS EffD 46-02-003 Blue Applicariop Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRADE ELEMED FEE ❑ Surcharge Fee ❑ Other FEE <br /> INSPECTOR# Z rf VALID . to ❑ Food handler <br /> ❑ Check# ADIOUNTPAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTINGOMCE Date <br /> RRud Pmv <br />