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SAN * AQUIN COUNTY ENV7TONMENTAL I-#EALTII DEPARTME T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ©New EH Pro am at Existing Facility <br /> ❑New EH Program and New Facility <br /> Facilif'ID () Pro rale Record ID <br /> ` <br /> Facility Address I— GCA <br /> r � <br /> (Please Check the appropriate description and specify sjTe�number of units and,Rertinent information.) <br /> FOOD PROGRAM(1640) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES El No <br /> ❑ <br /> Commissary ❑ Dry storage only © with Food Preparation ❑Vending Maellines Number of Units <br /> ❑ <br /> 13 Retail Market----Square footage ❑with Meat Market only 13 Multiple Departments [I Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle----Make License# Sticker# <br /> Registration# Color <br /> 11 Mobile Food Prep Unit--Make Veliicle Type <br /> License# Sticker# <br /> Registration# to 13 Ice Plant <br /> _ <br /> ❑Temporary Food Facility----Dates of operation from ❑ Produce Stand <br /> 17 Special Event --Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> E3❑ Grade A Dalry Grade B Dairy C3 Milk Dispenser Number of Containers in MaIti-Head Unit <br /> COPA 0 State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(22W)' f <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle 1 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 By Rule Fixed Unit ❑ -By-Rule Household Hazardous Waste <br /> XABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST ' <br /> UNDERGROUND STORAGE TANK(UST}PROGRAM(2300)Use USIA and B o <br /> HOUSING PROGRAM(2440) <br /> ❑ <br /> Number of Units Jail or Exempt Institution—Number of Units <br /> ©HoteUMotei . <br /> Eusployec Housing(2700)Use Employ4 jfousirr /Labor Camp AW—Header,Form . <br /> � UNDERGROUND INJECTION CONTROL—(3000) <br /> SITE_MITIGATION(2900) <br /> Q NPLISEP Cleanup Site 11 UIC Site <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local I1W Cleanup Site. <br /> 11 Abandoned HW Site [3not:NPLISEP Cleanup Site ❑RWQCB Cleanup Site Q Wafer Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> ❑P901 ❑ Spa (I Out of Service PooVSpa 13 Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> VECTOR.'ONTROL PROGRAM(4000) <br /> 13 Kennel <br /> ❑Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> [3 Tattooing(4121) L3 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 /> ❑ Sludge/Ash Site <br /> 13 Landfill 11 Transfer Station [I Ag 1 Cannery Waste Site b <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility 17 CIA•Landrill Site <br /> ❑Refuse Vehicles--Number of Units ❑Dumpsfers>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----Z 2-10 © 11-6o------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Mae Applicadort Form <br /> EMERGENCY NOTIFICATION FOR THIS F=ACILITY ANWOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE '- ❑ Other FEE <br /> INSkECI'OR# F <br /> T VALID . to 17 Food Handler <br /> 09 <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> © Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> M­trfilP Rrrnrrl Pinl- <br />