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SCAN JOAQUIN COUNTY EN'--'ZONMENTAL IIEALTII DETAWI "?N1' <br /> MAS'TERFILE h .ORD INFOItMATION FORM <br /> ❑ New El-1 Pro ram at Existing FacilitX New Eli Pro ram and New Facility <br /> Facilit IU Pro rani Record 1D <br /> Facility Address 1 L- 263 I t:3 5;c-,t,,, 253;2 <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 11 _ _ License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration ll License 11 _ Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to _ ❑ Produce Stand <br /> DAIRYPROGRAM(2000) <br /> ❑ Grade A Dalry ❑ (:rade it Dairy ❑ Milk Dispenser---Number of Containers in Multi-I lead Unit <br /> CUPA ❑ State Facility Surcharge(2399) —- <br /> HAZARDOUS WASTE,, PROGRAM(2200) <br /> ❑ Ilazardous Waste Generator-----------=Pons 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-lay-Rule Fixed Unit ❑ Permit-lay-Rule I(ousehold Ilazardous Waste <br /> ❑ ABOVEGROUND S'T'ORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ liotel/Motel-----—Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Fmptoyee Housing(2700) Use Employee flousinglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ R%N'QCB 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(4 100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License 1l 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 /> ❑ 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 ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----112- 10-------❑ 11 -60------El >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EIID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph <br /> PROGRAM FumENT ! x-7+0 FEF; ❑ Surch:uge FEE ❑ Other 11 FF <br /> INSPECTOR# T �c PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash RE-VIEWED BY ACCOUNTING OFFICE Date 3 3d ) <br /> 48-02-034 Masterfile Record Pink <br /> 11/18/03 <br />