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AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ST <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility []New EH Program <br /> fn__ and New Facility <br /> Facili ID �l7 Program Record ID !''C.i 5 Z3 225 <br /> Facility Address 90SD l <br /> (Please Check the appropriate description and specify size,number of ullits and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑Drystorageonly ❑ 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 /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 5'4V-1r1 <br /> razardous 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 13 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(2300)Use USTA 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 Emalovee Housing/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 /> El 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--Re. License# Capacity Vehicle# <br /> 13 Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 13 Landfill 11 Transfer Station 11Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles­Numberof Units0Dumpsters>20cuyd---NumberofUnits ❑ 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 ❑ Veterinary Clinic ❑ Common Storage Facility----❑ 2- 10-----❑ 11-60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Farm <br /> . EMERGEN Y NOT( (CATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON V^'"A I`" 02f - Day Ph — V Night Ph <br /> PROGRAM ELEMENT 22.2.0 FEE ❑ Surcharge Fee ❑ Other FEE <br /> INSPECTOR# 1 —1 _ PERMIi VALID 2 to ��1 ❑ Food Handler <br /> ❑ Check# AMOUNT PAID t,t- Date INVOICE# /7-4 q t.—D <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE 7Zt-- Date 41 D <br /> Lf <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />