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')AIN JUAQUIIN (..UU1N 1 Y L1N `� lKU1N1V1L1N 1 AL IILALI 1_1"L' l -AK l 1V1L' 1N 1 <br />MASTERFILT:._ CORD INFORMATION FORM <br />EH Program at Existing Facil <br />❑New EH Program and New Faci <br />Facility ID 2— �� / Program Record ID <br />�.acility Address <br />(Please Check the appropriate description and specify siM number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: 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 <br />Registration # License # <br />❑ Mobile Food Prep Unit --Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility -----Dates of operation from to <br />❑ Special Event --Dates of operation from to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ 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 />HAZARDOUS WASTE PROGRAM (2200) <br />;Q Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt 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 ❑ Permit -By -Rule Household Hazardous Waste <br />,.ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee tiousing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # _ <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />Capacity _ <br />❑ Chemical Toilets <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Vehicle # <br />Number of Units <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 02-10 ------- ❑ 11 - 60 ------ El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use P{VS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Nieht Ph <br />PROGRAMELEMENT _ 23 3r) ft ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # j PERMIT VALID / to 11Food Handler <br />ElCheck # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date q 6 <br />48=02-034 Masterfile Record Pink <br />11/18/03 <br />