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S ' J01AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT d MASTERFILE RECORD"INFORMATION FORM �I ❑blew EH Pro and New Facility New EH Pgr roam at ExistingFacility Faciiit ID�� ? Pro ram Record ID �� i�U c�Z a T ' Facility�kpddress Ed S T>,A (Please Check the appropriate description and specify sM number of units and pertinent iaformatiou,) FOOD pROrGRAM(1600) uare Footer a Food Handlers Course re Hired: YEs❑ No ❑ ❑Restautlnt: Seating Capacityg ❑Yendina Machines—Number of Units ❑ Commisiary ❑ Dry storage only [1 with Food Preparation b ❑Retail Market---Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only 11 Vehicle Type Color [I Mobile Food Vehicle----Make License# Sticker# Registration# Color [3 Mobile Food Prep Unit--Make Veliicle Type Registration# License# Sticker# ❑ Ice Plant ❑ Tempolry Food Facility----Dates of operation from to ❑-Produce Stand [3 Special Event --Dates of operation from to DAIRY PROGRAM(2000 ❑Grade.A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit "COPA [3state Facility Surcharge(2399) IIA .RDOUS WASTE PROGRAM(2200) t di,..Iiazardous Waste Generafar-=--- Tons Generated Per Year [3 Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) t ❑Appliance Recyclers(2217) Tiered Permitting Facility— - ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) [I permit-By-Rule,Fixed Unit t-By--Rule Household Hazardous Waste OVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of Ao s UNDERGROUND STORAGE TANK(US7)PROGRAM(2300)Use UST A an B HOUSING PROGRAM•(2400) 13 Ilotel/AMotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Em io ee Houslnp/Labor Come flpplication Form SITE MI1}'IGATION(2900) UNDERGROUND INJECTION CONTROL(30W) . -❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup site. ❑NPLISEP Cleanup Site ❑UIC Site ❑ Abandoned IiW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑\Yater Qnaiity Remediation Site RECREQ�TIONAL HEALTIi PROGRAM(3600) Number oaf Pools/Spas at Facility ❑Pgoi ❑ Spa ❑Out of Service P90USpa ❑Natural Bathing Area VECTOA.CONTROL PROGRAM(4000) 13Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID SM1IASTE PROGRAM(4200) 11Pumper Vehicle Registration# License# Capacity Vehicle# ❑Pumper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site 0 SiudgelAsh Site ❑Waste Tire Facility 11 Compost Facility ❑ProcesslRecycle Facility 11CIA CIA-Landfill Site ❑Reflic"e Vehicles--Number of Units ElDumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDIAL WASTE PROGRAM(4500) 11 Primary Care ❑Acute Care ❑Skilled Nursing 13 Large Generator 0 Small Generator ❑ Limited Ilanler 11 Tra�usfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10 ❑ 11-60_0>60 generators PURIL19 WATER SYSTEM PROGRAM(4600)Use PHISEHD 46-02-003 BIueAnPlicalion Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTL PERSON ft Day Ph Night Ph PROGRAN1ELEMENtiT U FU ❑ Surcharge FEE". ❑ Other FEE INSPEL 11 OR# LID io ❑Tood Handler 'llC 13 Check AMOUNT PAID Date INVOICE# # ❑ C.hI REviEWED$ Y AccouNTING OFFICE Date - -y� AAacrrflr Rpr.nrrl Pint-