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l,- 0 _ • <br /> • SAN TOAQUTIN COUNTY IJNVIRONMENT'AI.HEALTH DEPARTMENT <br /> 11IASTERFIL.E RECORD INFOrnIATION FORM <br /> New EH at Program Existin facility ❑New EH Program and and New facilityN. _ <br /> Facilityll) ��bOd 5 Pro ram Record ID 'Pfi v5 37�0Y 3 <br /> Facility Address �b0`,OU�� G�n�5c,� S� 5 C(k1'0� <br /> (Please Check the appropriate descriptioa and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Reatauraat: Seating Capacity Square Footage Food handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Vending Machines—Number of Units <br /> ElRetail Market—S-quare 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 Veliicle 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 /> ®AIRY PROGRAM(200 ) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk-Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IjA7_ARDOUS WASTE PROGRAM(2200) I <br /> ❑hazardous Waste Generator.— Tons Generated Per Year ❑ Recycle/ETempt System(2299) <br /> ❑CRT Offsite Handlers(2216) ❑ Silver Only(2222) _ ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perrnit-By-Rule Fined 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 E forms <br /> ROUSING PROGRAM(2400) <br /> ❑ Iiotelnilotel Number of Units El Jail or Exempt Institution Number of Units <br /> Employee Ifoeufing(2700)Use Employee ffousiazlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAI'Site ❑Local IIW Cleanup Site, ❑ NPIJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned I1W Site ❑ non-NPLISEP 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> El 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 /> 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 /> ❑ Primary Care ❑Acute Care ❑ SU-1cdNursing ❑ Large Generator Cl Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ I1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P1fSFFFD f6-02-003 BlrceApplicalion Forrtr <br /> EMERGENCY NOTIFICATION FOR Trlts FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> I'ROGRAMELEME, rT [A`I LI O I� ❑ Surcharge FEE El Other FEE <br /> INSPFCTOR# �S 0 L(���'Z� PERMITVAIiDto ❑ food Handler__ <br /> E Chick i' 7 10UN"F P.4ty Date !NVOICE It --- <br /> (('` <br /> Cash IZLV[tt'1kDIIY �li al`7 i3 4CC0[JPdTl1.G0FF[CE Date �� <br />