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I SAN JOAQUIN COUNTY ENVIRONMENTAL IIEAI TI1 DEPARTMENT I <br />h1ASTERFILE RECORD INFORMATION FORM l <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 required:. YEs ❑ NO ❑ <br />❑ Commissary ❑ Dry storage only El with Food Preparation ❑Fending Machines —Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle ---Make <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility —Dates of operation <br />❑ Special Event —Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />from to <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (20W) n <br />❑ Grade A Dairy [3Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />IIAZARDOUS WASTE PROGRAM (2200) " a <br />❑ 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 />Ef Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />BVEUND STORAGE TANK FACILITY (AST) 0399) Number of AST <br />A�NODERCG4RO <br />OUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Ilotenlotel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee lfousine/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ EnAroamental Assessment ❑ UST -CAF Site ❑ Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned 111V Site ❑ non-NPUSEP 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 />❑ Poultry Farm Maximum number of birds 11 Kennel <br />TATTOO BODY 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 />13Laudfiitl ❑ Transfer Station 11 Ag I Cannery Waste Site ❑Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />11 Primary Care ❑ Acute Care 11 Skilled Nursing 13 Large Generator 11 Small Generator ❑ Limited IIaulcr <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --0 2 - 10 ❑ 11 - 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PHS EIfD 46-02-003 Mae Application Form <br />CONTACT PERSON <br />PROGRAM F.LENIEN'T LZ <br />INSPECTOR # <br />EMERGENCY NOTIFICATION rOR THIS FACILITY ANDIOR PROGRAM <br />Day Ph Night Ph <br />FEE ❑ Surcharge FEE ❑ Other FEF. <br />PFRMITVALID . to ❑ Food Handler <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWEDDY C ' gee <br />Date <br />ACCOUNTING OFFICE <br />INVOICE # <br />Date V <br />