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SAWJOAQUIN COUNTY�VIRONMENTAL HEALTH DEPAF"�RENT, <br /> MASTERFILE RECORD INFORMATION FORM 'i <br /> ❑ New EH Program at Existing Facility ew EH Program and New Facility <br /> Facility ID F;0}-bp .237-7 J Pro ram ecord ID pR, 5fI L14. <br /> Facility Address i� <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) l <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 ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type 1 Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type i Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> C PA <br /> �ai <br /> zardous Materials Business Plan (1900) Number of chemicals: <br /> ffff❑�`�`CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST) (2840) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution --'--Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor CamlQ Application Fonn <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB 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) j <br /> ❑ Poultry Farm-------Maximum number of birds i ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) j <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art F facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) 11 <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 ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ; ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters a 20 cu yd (#or 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 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br /> ENI GENcy-NoTIFICATI54N FOR THIS FACILITY AND/OR PROGRAM Q <br /> CONTACT PERSON r CL Day Ph S`0.3 - 2_� -r�Nt t Ph <br /> PROGRAM ELEMENT 2- 1 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# -e--2—PERMIT VALID J_, to 11 Food Handler <br /> ❑ Check# r AMOUNT PAID�6 i� 1 �/�Jate / INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date bi3j D f 1 Ll- <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 1123113 <br />