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17! <br /> AN JOAQUIN COUNTY f `IRONMENTAL HEALTH DEPAR =NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ew EH Program and New Facility <br /> Facilit ID DD ;Z y 7 3 Program Record ID ARD 5�f355 g <br /> Facility Address 2 L 4 C1 i-J� oo S�ZGS' <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/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 ❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to [] CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals: " <br /> ❑ CaIARP Program El Program 1 Facility 1:1 Program 2 Facility / Program 3 F cility <br /> Plazardous Waste Generator(2200)----------> Tons Generated Per Year I V� $ 41 1 '" <br /> ElTiered Permitting Facility-------> ElCA(2232) ElCE (2233, 2234, 2235, 2237) Ll P13-R-(-22-31 1-PBR-NH (2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee 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 /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (#of Units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ 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 END 46-02-003 Blue Application Fonn <br /> JMERGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON ��/ .� , S Day Ph Lr< S4J1-0 r Night Ph <br /> PROGRAM ELEMENT �'� FEE �3 <br /> El Surcharge FEE El Other FEE <br /> INSPECTOR# A Ja- h(i' PERMIT VALID to ❑ Food Handier <br /> � <br /> ❑ Check# AMOUNT PAID Date 7 INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date (3 / <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 <br />