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-AN JOAQUIN COUNTY 'IRONMENTAL HEALTH DEPAF ENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID f 'j J, Program Record ID Facility Address 3 % Ll- /Z 141 - `T ee219R/L2�rC ✓4' (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 required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Special Event Dates of operation from to DAIRY PROGRAM (2000) _ ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ 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 Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility------------------- ❑ Conditionally Authorized (CA) ❑ Conditionall empt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -B ul ousehold Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B for s HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Instituti ----Number of Units Employee Housing (2700) Use Employee Housin_glLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (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) ❑ 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 (# of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ 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 Day Ph Night Ph PROGRAM ELEMENT FEE ❑Surcharge FEE El Other FEE INSPECTOR #r" J i412V PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID DateINVOICE # C] Cash REVIEWED BY ACCOUNTING OFFICE Q� Date �3 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07