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FSAN JOAQUIN COUNTY ' (IRONMENTAL HEALTH DEPAR 'ENT <br /> MASTERFILE RECORD INFORMATION FORM ..F <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facili <br /> Facility ID Program Record ID <br /> Facility Address Q S 7 6 DO A/ AUGNU� <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 ❑ 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 /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event 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 /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/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 UnitIt-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST) (2390) Number of AS'i"PlIr <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use UST A an forms <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution --Number of Units <br /> Employee Housing(2700) Use Employee Housina/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ 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) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Tattooing(4121) ❑ 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 /> ❑ 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 I#or units) ❑ Dumpsters>20 cu yd (#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 ❑ 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 AND/OR PROGRAM <br /> CONTACT PERSON [1 Day Ph Night Ph <br /> PROGRAM ELEMENT Z a T FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# gr"-I? (PERMIT VALID t0 ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE / Date i/ <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />