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SAIF JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION MASTFRFILE RECORD Pl iFORAMATION FORM(EH 00 69) New EH Pro at Existing Facility ❑New EH Pro and New Facili Facili ID Program Record ID PP-,o Sa-( S `7 Facility Address 9Rkalap IVi Q,;F' � '2-2 (Please Check the appropriate description and specify size-number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity -- Square Footage Food Handlers Course required: YF5 13 No 13 ❑ 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 Color Type ❑ Mobile Food Vehicle--Make Vehicle Sticker# Registration# License# Vehicle Type Color ❑ Mobile Food Prep Registration 9 Sticker# Regisnation# License# to ❑ Ice Plant ❑ Temporary Food Facility--Dates of operation from ❑ produce Stand ❑ Special Event - Dates of operation from 10 DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) - HAZAIjHOUS WASTE PROGRAM(2200) L- Hazardous Waste Generator------------ —Toru Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ ❑ Hotel/Motel------Number of Units Jailor Exempt institution—Number of Units Employee Housing(2700)Use Cama llaollrarion Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site [I UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area Number of PooWSpas at Facility VECTOR CONTROL PROGRAM(4000) ❑ Kennel ❑ Poultry Farm—Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) ❑ Tattooing(4121) ❑ Body Piercing(4120) LIQUID WASTE PROGRAM(4200) Vehicle# ❑ Pumper Vehicle—Registration# License# Capacity. ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units�— SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash e/Ash Site ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site g ❑ Process/Rec cle Facility ❑ CIA Landfill Site ❑ Waste Tire Facility ❑ Compost Facility _ y ❑ Farm/Ranch Cleanup Site [IRefuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Uniu MEDICAL WASTE PROGRAM(4500) ❑ Large Generator [I Small Generator [JLimitedtsr ❑ imary Care 11 Acute Care C1 Skilled Nursing 11 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10—❑ I 1-60—❑ 60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Farm EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 7Q?�o FEE D ❑Surcharge/FEE [IOther FEE (�— to (� f 3(( ❑Food Handler INSPECTOR#-� � PERMrr VALID INVOICE# 4 ❑ Check# AiMOUNT PAID �l_�G� _ Date J( Date S/S7o3' ACCOf Kmr,OFFICE -y„c.