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r � A <br /> SAN JOA QUIN COUNTY E1_`IVIRONMEN TAL HEALTH DEPARTI�'IENT <br /> MA-STERFILE REECORD INFORRIATIOIN F0101 <br /> ❑New EH Program at Existing Facility Wlw EH Program and NcN,) Facility <br /> Facility ID0 X383 1?ra cram Record ID Q-c�S3S3 33 <br /> Facility address <br /> (Please Check the appropriate des'criptioa and sped size,number of units and perffnen(infor-mation.) <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 lilachiaes—Number of Units <br /> ❑ Retail lllarl:et—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 /> ❑ Tem pomiy Food(Facility—Dates of operation from to El ice Plant <br /> ❑ Spt-cial Eveat —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-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> IIA2ARDOUS WASTE PROGRAM(2200) 1 <br /> ❑ Hazardous Waste Generator Tons Generated Per Year ❑Recycle I Eiempt Systern(2299) <br /> ❑ CRT Offsite handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally A ithorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule F'Ked Unit ❑ Pe=t-By-Rule I-1-ouseliold Ha—zardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAl41(2300)Use USFA cnd B(arras <br /> HOUSING PROGRAM(2400) <br /> ❑ Ito tenlotel Number of Units ❑Jail or E•tempt lastitutron Nurnber of Units <br /> MpjoyE:.I1ousin€g(2700)$Ise Employee Flousiri jT/L-a6ar Camp Applicafiort Form <br /> SITE C,IITIGA`9'IOH(2900) UNDERGROUND 114JECTION CONTROL(3000) <br /> ❑ EaAronmeatal ASse_=sruent ❑UST-CAS'Site ❑Local IfW Cleanup Site. ❑Nr ISE?Cteanup Site ❑ UIC Site <br /> ❑ Abandoned 111"A'Site ❑ non-NPUSEP Cleanup Site ❑WN�rOCB Cleaaup Site ❑iVater Quality Remediation Site <br /> RECREA T 90NAL HEALTH PROGRAM(3600) <br /> Number of PoolsiSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pooyspa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑ Poultry Farrar Maximum number of birds ❑ Kennel <br /> d A`rTOO.BODY PIERCING,P ERMAHEMT COSME i IG PROGRAM(4100) <br /> ❑ T aftooing('1121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> E] Pumper Vehicle—Registration ft License# Capacity Vehicle 4 <br /> ❑ Pumper Yard ❑ Package age Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID i[ASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery iVaste Site ❑ Sludge/Ash Site <br /> 14 waste Tire Facility ❑ Compost Facility ❑ Pracess/Recfcle Facility ❑ CIA Landfill Site <br /> ❑P.efuse Vehicles—Number of Units ❑ DumpsEers>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PPOGRAPII(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing El Large Generator El Small Generator ElLimited Hauler <br /> ❑ Transfer Station El Veterioary Clinic ❑ Common Storage Facility----E] 2-10 ❑ l l -60---❑ >60 generators <br /> PUBLIC WATER SYS T EN1 PROGRAM(4600) Use PHSr,1[D-4642-003 BraeAppricarian Form <br /> EMERGENCY VOTIFICAs Iota FOR i Itis FACILITY ANDloP.PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> rp,eGRAm ELrAiENT t I'cc ElSurcliarge FEE El Other FEF <br /> l�tsrEc-roa# �k PPC-PJ,11T VAL1D to ❑ Food handler <br /> ❑ Chcckt AmoUNT PAID Date 1t1V0ICL- <br /> ❑ C sh S:EV!C',,EDBY AC ClrfIrw,ji_)FFicE Da(,- 11J <br />