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FUSAN JOAQUIN COUNTY, ONMENTAL HEALTH DEP NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> R New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID �-A 0004 -5-7 z) Pro ram Record ID �2oSa3 3 fo <br /> Facility Address. S ,5ZA Sc7c7 <br /> (Please Check the appropriate description and specify size,number of units and pertine t 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 Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(23 00)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution------Number of Units <br /> Employee Housing(2700)Use Employee HousinQ/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-NPL/SEP 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(412 1) ❑ 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--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator DEPARTMENT NO LONGER <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 21 <br /> INSPECTS WASTE TIRE <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application For <br /> FACILITIES. It is a State run <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OA program effective 7/1/2017. <br /> CONTACT PERSON c/ Day Ph �_��_ <br /> L <br /> RAM ELEMENT / a FEE ❑ Surcharge FEE ❑ Other FEE <br /> CTOR# y !S PERMIT VALID to ❑ Food Handler <br /> eck# AMOUNT PAID Date INVOICE# <br /> h REVIEWED BY ACCOUNTING OFFICE Date 31005 <br /> 48-02-034 Nlasteifile Record-Pink <br />