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$AN JOAQUIN COUNTY 'iONNIENTAL HEALTH DEPAR VT . MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facilit "' Pro ram Record ID Facilit ID �v� Facility on.) Address 0 5 D W, W2 + S� {Please check the appropriate description and specify size, number of units and pertinent informati FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No El ❑ Comm}ssary ❑ Dry storage only E3 with Food Preparation ❑Vending Machines Number of Units ❑ Retail�IVlarket----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ MobileFood Vehicle--Make Vehicle Type Color Registration# License# Sticker El Mobile�IFood Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Tempirary Food Facility--Dates of operation from to El Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PR'D GRAM (2000) 13 Grad�A Dairy 13 Grade B Dairy ❑ Milk Disp enser-Number of Containers in Multi-Head Unit CUPA Haza�Pous Materials Business Plan (1900) Number of chemicals: Cal RP Program ElProgram 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazarit dous Waste Generator(2240)----------> Tans Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) 13 CE(2233,2234, 2235,2237) ❑ PBR(2231) ❑ PBR HHW{2236) ❑ Abovkground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ OtherICUPA Program HOUSINGrPROGRAM (2400) ❑ HotellMotel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee�Housing (2700) Use Employee Housin /Labor Camg Application Form SITE MITId ATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Envir8nmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number 8f Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTORItONTROL PROGRAM(4000) ❑ Pouidy Farm-------Maximum number of birds ❑ Kennel TATTOO,CODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body lArt Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID ASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# 13 Pumper Yard 13 Package Treatment Plant El Chemical Toilets----Number of Units SOLID ASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#or Units) ❑ Farm/Ranch Cleanup Site MEDICAJ6ASTE PROGRAM(4500) ❑ Primatry Care ❑ Acute Care ❑ Skilled Nursing 13Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application For] II EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTAC4�PERSON Day Ph Night Ph PROGRAIM ELEMENT L 1 U FEE_ ()C ❑ Surcharge FEE 1:1 Other FEE INSPECTOR# 2 L4 —[ PERMIT VALID to 13Food Handler ❑ Check AMOUNT PAID , Date _ INVOICE# 1:1 Cash REVIEWED BY 12 'l3� f3 � f�J ACCOUNTING OFFICE Date A25 48-02-034 MASTERFILE RECqRD INFORMATION PINK 1123113