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ffSANOAQUIN COUNTY IRONMENTAL HEALTH DEPA ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existin Facility ❑New EH Program and New Facility <br /> Facility ID EH ( I 'l Pro ram Record ID PI` 0 � ( Z 5 <br /> Facility Address -701 (d )11vn (y"a V 4Z n le e- �y <br /> (Please check the appropriate description 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 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 /> Color. <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Sticker# <br /> Registration# License# <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 /> CUPA <br /> X Hazardous Materials Business Plan (1900) Number of chemicals: <br /> 13CaIARP Program [I Program 1 Facility El Program <br /> 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) ❑ PER 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 /> El 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 /> 13 Environmental Assessment ❑ UST-CAP Site [I Local HW Cleanup Site ❑ NPL/SEP 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) ❑ 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) Y <br /> Capacit Vehicle# <br /> ❑ Pumper Vehicle Registration# License# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) ElSludge/Ash Site <br /> 11 Landfill 13 Transfer Station ❑ Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ED Waste Tire Facility E] Compost Facility ❑ Process/Recycle Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ 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 ❑ 2- 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 ANDIOR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> (�/ ❑ Surcharge FEE [IOther FEE <br /> PROGRAM ELE NT I FEE ❑ Food Handler <br /> INSPECTOR# C.(-it PERMIT VALID to <br /> El Check# <br /> AMOUNT PAID Date INVOICE# <br /> 11Cash REVIEWED BY In 111S ACCOUNTING OFFICE '' Date <br /> MASTERFILE RE RDIWORNIAI ION PINK <br /> 48-02-034 <br /> 1123113 <br />