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SA-wN JOAQUIN COUNTY EN" RONNIEN 1'AL REALM DEPARl"ENT <br />MASTERFILE I --ORD INFORNIATION FORM <br />❑,New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facilitv ID Program Record ID )%'/' 7 � y .i J <br />Facility Address Ags W Fr-i_,�-- <br />(Please Check the appropriate description and specify sib 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 <br />Rcgistration ti License # <br />❑ Mobile Food Prep Unit --Make Vehicle Type <br />Rcgistration # 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 Dalry ❑ 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 (221 s) ❑ 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 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 Housing/Labor Camp 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ 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 />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets -------Number of Units <br />❑ Landfill <br />❑ Transfer Station <br />❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility <br />❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number <br />of Units <br />❑ Dumpsters > 20 cu yd ----Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care <br />❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small <br />Generator ❑ Limited Hauler <br />❑ Transfer Station <br />❑ Veterinary Clinic <br />❑ Common Storage Facility ----- 112- 10 ------- <br />❑ 1 1 - 60 ------ 11 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EHD 46-01-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT —7 40 FEE Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERMIT VALID to ❑ Food Handler <br />❑ Check N AMOUNT PAID Date _ INVOICE # <br />Cl dash Rtmt:wltn ny AcCOUNTINU Or•rlcii f ! Date <br />48=02-034 Masterfile Record Pink <br />11/18/03 <br />