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FSS" JOAQUIN COUNTY ENVIRONMENTAL HEALTH'DEPARTMENT <br /> MASARFILE RECORD INFORMATION FORAT <br /> ❑New EH ProM at Existing Facility ®New EH Promm and New Facility <br /> Facili ID �-�:'. :... : Pro ram Record ID <br /> Facility Address X78 �i►��evl�r ��_ �i s/zj <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 ❑Vending,Machines.—Number'of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple]Depaltrticnts. ❑Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle- Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type I 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 /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Ilead 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(22 is) ❑ 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.8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee HeusinZjabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL( 000 <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local I W Cleanup Site ❑NPL/SEP Cleanup Site ❑ WC Site <br /> ❑Abandoned I1W Site ❑non-NPIJSEP 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 ❑ Kennel <br /> TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(412 1) ❑ 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 /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> U Waste Tire Facility ❑ Compost Facility ❑Proccss/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles.—Number of Units ❑Durnpsters>20 cu yd—Number of Units ❑ Firm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-13 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EFID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Lf-7L FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# Ltb 4t5 PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �` <br />