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S'AN JOAQUIN COUNTY EN''-IONMENTAL HEALTH DEPART NT <br />MASTERFILE Rr.CORD INFORMATION FORM <br />New EFI Program at Existing Facil <br />❑New EH Pro <br />and New Facilit <br />II Facility ID F4 GO 1 (()0 l Program Record ID 11 <br />Facility Address <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 ❑ 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 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 Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <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 />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (23 90) Number of .-QST <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 Rousing (2700) Use Employee Housing/Labor Cantil 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 IiW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool ❑ Spa 11 Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # _ <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets ------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ 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 eu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care ❑ Acute Care [I Skilled Nursing El Large Generator El Small Generator El Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----❑ 2 - 10------- ❑ 11 - 60------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph Night Ph <br />PROGRAM EI.ENIENT EI i L' FEF: _ <br />INSPECTOR # (30 0 PERMIT VALID <br />❑ Check k AAIOUNT PAID <br />❑ Cash REVIF,N'ED BY T(2 J/5) <br />48-02-034 <br />10/6/2003 <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE _ <br />❑ Food Handler <br />INVOICE # <br />Date <br />Masterfile Record Pink <br />