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F!f <br /> JOAQUIN COUNTY 1<JNVIRONhZ1.1NTAL I��AI,TIi DIJPART11iCNT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 4 New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID FA 00 Program Record ID �-53-5 p <br /> Facility Address O - 6 m (A `t.abl <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 ❑Fending hlachines-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 if 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-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Gcnerator— Tons Generated Per Year ❑ Recycle I Excmpt 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 ❑ Pemut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotentotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee ffousin,*4xbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11Environmental Assessment ❑ UST-CAP Site 11Local IIW Cleanup Site, 11 NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IiW Site ❑ non-NPL/SEP Cleanup Site ❑R\VQCB Cleanup Site ❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Oul 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) ❑ Permauent 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 11 Transfer Station El Ag I Cannery Waste Site <br /> ❑ 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 IIauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--D 2- I0 ❑ I 1 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS FIID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> p�rry�/ i <br /> PROGRANtELEMEIYT LtO FEE T ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALID to ❑ Food handler <br /> ❑ Check AMOUNT PAID Date INVOICE# <br /> ❑ Cash P_EVIEWED BY QG q j 1 ll) ACCOUNTING OFFICE Datc <br />