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SAMJOAQUIN COUNTY ENV4#NMENTAL HEALTH DEPART*T <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility []New EH Pro ram and New Facility <br /> Facility ID L) (0-7 C,Z Program Record ID <br /> Facility Address1� �' � GOA �5a2y� <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 Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----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 /> ❑ 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)(2390) Number of AST <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 Housing(2700) Use Employee HousinglLabor Carp 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 HW 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 'El Out of Service Pool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM.(4000) <br /> 11 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 /> 11 Landfill ❑ 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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> [I Primary Care El Acute Care 11 Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> ❑ Transfer Station El Veterinary Clinic El Common Storage Facility----13 2- 10------- El 11 -60--- -171 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON �i Day Ph Night Ph <br /> PROGRAM ELEMENT % 7y FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# `le go PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE#// <br /> ❑ Cash REVIEWED BY &_ �Z� O ACCOUNTING OFFICE Date 6, D`-' <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/62003 <br />