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SARA,JOAQUIN COUNTY I&IRONMENTAL HEALTH DEPAROENT FMASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility FlFacirity ID Q Program Record ID Facility Address 75- (Please (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: ves El No El ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehide 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 ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3/IFacility Hazardous Waste Generator(2200)---------> Tons Generated Per Year��l` 1 L 0'I 1� Tiered Permitting Facility-------> 13 CA(2232) El CE (2233, 2234, 2235, 2237) [1 PBR(2231) ❑ PBR HHW(2236) ❑ 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) ❑ 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) ❑ Environmental Assessment [I UST-CAP Site ❑ Local HW Cleanup Site LJNPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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) Capacity Vehicle# El Pumper Vehicle Registration# License# P Y ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site ❑ Landfill ❑ Transfer Station ElAg/Cannery Waste Site 9 ❑ Waste Tire Facility [I Compost Facility ❑ 11 CIA Landfill SiteProcess/Recycle Facility El Farm/Ranch Cleanup Site ❑ Refuse Vehicles (#of units) 11Dumpsters>20 cu yd (#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 ❑ 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 V L) ❑ Surcharge FEE ❑ Other FEE INSPECTOR 1 �i2 PERMITVALID C to laI lIZ71 11 Food Handler ❑ Check# AMOUNTID Date INVOICE# ❑ Cash REVIEWED BY (J F' (� ACCOUNTING OFFICE Date MAS TERFILE RECORD INFORMATION PINK 48-02-034 1/23/13