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it SAWJOAQUIN COUNTY `VIRONMENT4AL HEALTH DEPAFENT MASTERFILECORD INFORMATION FORM ❑ New EH Program at Existing Facilitv ❑New EH Pro ram and New Facilit Facilit ID Pro gram Record ID ,Z Facility Address 17 1, il (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course rem Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Mending Machines Number of Units ❑ Retail Market---Square footage ❑ with`�Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only 1:1 Mobile Food Vehicle--Make , Vehicle Type Color Registration# II License# Sticker# ❑ Mobile Food Prep Unit Make. Vehicle Type Color Registration# �� License# Sticker# ❑ Temporary Food Facility--Dates of operation from �M to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) 1:1 Grade A Dairy 13 Grade B Dairy 13 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ---------- ❑ Silver.1Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditional! xempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit- - ule ousehold Hazardous Waste BOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST NDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B fo Z-- HOUSING PROGRAM(2400) iM ❑ Hotel/Motel------Number of Units 1 ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housin /Labor Carno APPLIcation Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ElEnvironmental Assessment 1:1 UST-CAP Site 11 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site El UIC Site ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup lSite ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool 01.Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) 11 Poultry Farm----Maximum number of birds i 11 Kennel r TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Pierci�g(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) 11 ❑ 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) D Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) i ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large 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 Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Q Day Ph Night Ph PROGRAM ELEMENT FEE k� __ 13Surcharge FEE ElOther FEE INSPECTOR 41 PERMIT VALID �1k to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date a fp 4M2-034 MASTERFILE RECORD INFORMATION PINK 11/15/07