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SAN JOAQUIN C:OUN'1 Y ENVIRONNIEN IAL HEAL11-1 OLI'ARIAIEN'1' <br /> MASTE ILE CORD INFORMATION FORM <br /> oNew EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address —7 , = D,r-XI — <br /> (Please Check the appropriate descrip ion 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 on y ❑ 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-----Dat s of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operatio from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ rade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA El State Facility Surcharg (2399) <br /> HAZARDOUS WASTE PROC M(2200) <br /> �$l—Hazardous Waste Gen rator------------Tons Generated Per Year C ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handler (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facilit ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORA E TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORA E 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 Employe 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 1:1RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROG M(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4 00) <br /> ❑ Poultry Farm Maximum nur ber of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERN ANENT 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 /> ❑ Landfill ❑ Trans er Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Comp st Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units — El Dumpsters>20 cu yd ----Number of Units ElFarm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(450 ) <br /> ❑ Primary Care El Acute Car ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> ElTransfer Station ElVeterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ I 1 -60------El >60 generators <br /> PUBLIC WATER SYSTEM PROG M(4600) Use PffS EHD 46-02-003 Blue Application Form <br /> E ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT a2 Z J FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# L->j(, PE IT VALID to ElFood Handler <br /> ❑ Check# AMOU T PAID Date VOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE. LL Date 0.7 <br /> 48=02-034 Masterfile Record Pink <br /> 11/18/03 <br />