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gFacili <br /> JOAQUIN COUNTYL.VIRONNIENTAL HEALTH DEPA:�VAENT <br /> MASTERFII E RECORD I—TOWN ATIOr FORbI <br /> H Pro - at Existin Facili <br /> ❑New EH Pro am and New Facili - - <br /> ID ��� ( 6061 Pro ram Record ID PROsZ SLJ <br /> Facility Address L-00L-001 <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 11 No❑ <br /> - — <br /> ❑ Commissary 13 Dry storage only 13 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle-----Make License", Sticker# <br /> Registration# Color <br /> ❑ Mobile Food Prep Unit Make License#Vehicle Type Sticker# <br /> Registration# <br /> to ❑ Ice Plant <br /> ❑Temporary•Food Facility----Dates of operation from 11 Produce Stand <br /> ❑ Special Event --Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUP A ❑ State Facility Surcharge(2399) <br /> HAZA OUS WASTE PROGRAM(2200) S ❑Recycle/Exempt System 2299 <br /> azardous Waste Generator-----------Tons Generated Per Year Y p Y 0 ) <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 UST A and B forms <br /> HOUSINGPROGRAM(2400) <br /> ❑Jail or Exempt Institution—Number of Units <br /> (2 Hotel/Motel------Number of Units <br /> Employee Housing(2700)Use Emolovee Housine/Labor Camo Aoalication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site- [3 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site [j UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility 13 Pool El Spa [1 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Ca aci Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# P tY <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ p /Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑Transfer Station g ry ❑ CIA Landfill Site <br /> ❑Waste Tire Facility ❑ ❑ Process/Recycle Facility <br /> Compost Facility ❑ Farm/Ranch Cleanup Site <br /> 13 Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu}'d---Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 13 Large Generator [I Small Generator 1:1 Limited Hauler <br /> ❑ - <br /> Common Storage Facility----❑ 2-10--[3 11 -60----❑>60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PiVS EHD 46-02-003 BlaeAoalication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Y <br /> ttlF Y-� Day Ph 33`{030 Night Ph <br /> 7 10.0( ❑Surcharge FEE <br /> [J Other FEE <br /> PROGRAM ELEMENT �Z� Fee �_ [I Food Handler <br /> p <br /> INSPECTOR# d t113 PERMITVALID L 1 l 0 b to <br /> Date INVOICE# <br /> ❑Check# AMOUNTPAID_� Date G ��` <br /> 13 cash REVIEWED BY ACCOUNTNG OFFICE <br /> Masterfle Record Pink <br /> 48-02-034 <br /> 10/612003 <br />