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SAN JOAQUIN COUNTY ENVIRONMENTAL TIE,ALTIi DEPARTnILNT <br /> MASTERFIL.E RECORD INFORIYIATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH nnProggram and New Facility <br /> Facility ID O 0 a L o 3 7 Program Record ID <br /> fiacility Address 1 - � 1 +r_ L",�C,. 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 Elwith Food Preparation ElVendiag Machines—Number of Units <br /> 1:1Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ 1<Iobile Food 11chicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <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 /> Unit <br /> ❑Mill`Dis ers in Multi-11--ad <br /> ❑ Grade A Dairy El Grade B Dairy I/euser Number o <br /> f Cont�ut <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAM(2200) <br /> --- ons Generated Per Year El Recycle f Exempt System(2299) <br /> ncraQar= "T _ <br /> ❑hazardous Waste Ge <br /> ❑CRT 011site Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyelers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> Permit-By-Rule 11 Pcmait-By-Rule Fixed Unit ®P -Rule Household Hazardous Waste y <br /> D STORAGE TANK FACILITY(AST) 2390 Number of AS <br /> T <br /> ® ABOVEGROUN ( ( � , <br /> .UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forntr <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotenjotel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee I101rsirr j7/La'bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROt1ND INJECTION CONTROL(3000) <br /> Site ❑Local MV Cleanup 11NPL/SEP Cleanup Site 11UIC Site <br /> ❑ Environmental Assessment ®UST-CAP P Site, <br /> ❑ Abandoned HAY Site ❑ non-NPIdSEP Cleanup Site ❑R)VQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ 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 /> ❑ Pumper Vehicle—Registration ff 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/As4 Site <br /> Vast,Tire Facility ❑ Compost Facility ❑ProcesslRecycle 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 El Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UscPNVSEKD 46-02-003 BlueApplicalion Form <br /> EMERGENCY NOTIFICATION FORTrtis FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph _ <br /> PROGP-01ELENIENT Y _ FEE ❑ Surcharge FEE ❑ Other FEE <br /> z _ � / (,1,3 Y ❑ load Handler <br /> INSPECTOR# c�G PGFMITVACiD Z t0 —. <br /> E] Chea:i _ �Tovrrr P.a1u Date 11W010E 11 <br /> El Cash IEViEWED BY — ACCOUNTING OFFICE Date �___-- <br />