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• • <br /> S JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br /> MASTERFILE RECORD`INFORMATION FORM <br /> In New EH Programat EXisting Facility ❑New EH Pro and New Facility <br /> Facilit•H) l Program Record ID efL2 �3 <br /> Facility Address j/� 1� 1il1 CAg1?TX1& <br /> (Please Check the appropriate description and specify sa_Ls number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ 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 /> 11Temporary 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 /> IIAZARDOUS WASTE PROGRAM(2200) y <br /> ❑Hazardous Waste Generator--Tons Generated Per Year ❑ Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility - ❑Conditionally Authorized(CA) ❑ ditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit 't-By-Rule Household Hazardous Waste <br /> --ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST 6 - - <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B ms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use F.mIalom Ifousinz/Labor Camp Application Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPMEP Cleanup Site ❑UIC Site <br /> ❑Abandoned 11W Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑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/CanneryWaste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number 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 ❑\'eterivary Clinic ❑ Common Storage Facility---O 2-10--❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVSEIID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE [IOther FEE <br /> INSPECTOR# -3 RMIT VALID . to ❑ Food Handier <br /> ❑ Check# AMOUNTPAID Date INVOICE# _ <br /> ❑ Cash REvIEWEDBY AccouxrtNG OFFICE ` " Date <br /> R',a Pi,* <br />