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+F—+ S N JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT <br />1 NIASTERFILE RECORD INFORMATION FORM <br />ew EH Program at Existing Faci <br />Facility ID <br />Facility Address <br />❑New EH Program and New <br />el-- <br />Proaram Re53. <br />(Please Check the appropriate description and Specify�slize' numbeilof units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes 11 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 <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 />Veliicle 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 (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Numbcr of Containers in Multi-Ilead Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />IIAZARDOUS \WASTE PROGRAM (2200) d <br />❑ hazardous Waste Generator— Tons Generated Per Year ❑ Recycle I Exempt System (2299) <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) _ ❑ Appliance Reeyclers (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) Numbcr of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and R forms <br />HOUSING PROGRAM (2400) <br />❑ Ilotel/1ltotel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee housing (2700) Use Fmployee ffousinc/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAF Site ❑ Local IIW Cleanup Site, ElL/ <br />NPL/SEP Cleanup Site ❑ UIC Site <br />[IAbandoned IIW Site [Inon-NPLJSEP Cleanup Site ❑ RIVQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 11 Pool ❑ Spa 1.1Out of Service Pool/Spa El 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 (412 1) ❑ Body Piercing (4120) 11 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 El Transfer Station El Ag / Cannery Waste Site ❑ Sludge/Ash 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 El Skilled Nursing ❑ Large Generator El Small Generator 11 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --E] 2 - 10 ❑ 11 - 60 ---❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) UscPII:SF11-D46-02-003 Blue Application Foran <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRANiELEMEN'T LA -1 "(O FEE_ <br />INSPECTOR# dt4Db Pr-Rmn-VALID <br />❑ Check k AMOUNT PAID <br />❑ Cash R.EVIEWFI)BY 'Jc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler <br />Date INVOICE # _ <br />OFFICE Date / n <br />