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ESAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPAR NT MASTER RECORD INFORMATION FORM fNew EH Program at Existing Facility ❑New EH Program and New Facility . Facility iD Program Record ID P2o53a4�ao Facility Address ktV2e 0 rDlla� � (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❑Pw/MeattNumber ❑ Retail Market--Square footage Market only [3 Multiple Departments❑ Prepackaged Goods Only Color [I Mobile Food Vehicle--Make Vehicle Type Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Veh'ide Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA 11 Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility Hazardous Waste Generator(2200)O CA 2232ons ❑ CEGenera2233ted e2234r2235 ) ❑ PB(223 ❑ PER HHW (2236) ❑ Tiered Permitting Facility----- ( ) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ El Hotel/Motel--Number of Units Jail or Exempt Institution--Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) _ 11 Environmental Assessment El UST-CAP Site C1 Local HW Cleanup Site ❑ NPLISEP Cleanup Site El 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) ❑ Kennel ' ❑ Poultry Farm-------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) Vehicle# ❑ Pumper VehicleRegistration# License# Capacity ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site El Landfill LJ Transfer Station [IAg/Cannery Waste Site 9 ❑ Process/Recycle Facility 11 CIA Landfill Site El Waste Tire Facility ❑ Compost Facility EIDumpsters>20 cu yd (#of Units) [IFarm/Ranch Cleanup Site E2 Refuse Vehicles (#of units) MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility [:12-10 011 -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 / r Day Ph Night Ph PROGRAM ELEMENT 2 FEE Y"I ( o o ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALID t0 19-45) w ❑ Food.Handler ❑ Check#. AMOUNT PAID -,III � Date INVOICE# ❑ Cash REVIEWED SY UR ZC( ( ACCOUNTING OFFICE Date t >.41N04R MASTERFILE RECO DTION PINK 48-02-034 1123113