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uAN JOAQUIN COUNTY EI&RONMENTAL HEALTH DEPARTOT <br /> MASTERFILE R€CORD INFORMATION FORM <br /> New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID ` Program Record ID <br /> Facility Address to1_ Z �'L^e ( i::Lae <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM (1600) <br /> El Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: Yes 11 No 13 <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 Color. <br /> Registration# 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❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ <br /> El Grade A Dairy LI Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit_ <br /> CUPA <br /> Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CalARP 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) (2800) 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 /> ❑ <br /> ❑ Hotel/Motel------Number of Units Jail or Exempt Institution----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11Environmental Assessment ElUST-CAPSite ElLocal HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP 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) ❑ Kennel <br /> ❑ Poultry Farm-------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art 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) Vehicle# <br /> ❑ Pumper Vehicle Registration# License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) 11 Sludge/Ash Site <br /> 11 Landfill Ll Transfer Station 11Ag/Cannery Waste Site 1:1 CIA Landfill Site <br /> ❑ Waste Tire Facility El Compost Facility 11Process/Recycle Facility 11 CIA La Farm/Ranch Cleanup Site <br /> El Refuse Vehicles(#of units) ❑ Dumpsters> 20 cu yd (#of Units) <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 EHD 46-02.003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT T� �J _ FEE ❑ Surcharge FEE ❑ Other FEE <br /> �7� <br /> INSPECTOR# �J-- PERMITVALID tO ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date /' INVOICE# + <br /> //jj r Date <br /> 1:1Cash REVIEWED BY (/f" IZ I b I2 ACCOUNTING OFFICE MASTERFILE RECORD INFORMATION PINK <br /> 48-02-034 <br /> 1123113 <br />