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SAi`I JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORINT(EH 00 69) <br /> ❑New EH Pro am and New Facility <br /> ❑ New EH Program at Existing Facility D <br /> Facili ID Pro ram Record ID <br /> is ; to <br /> Facility Address 2a�� O <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Restaurant: Seating Capacity Square Footage <br /> ❑ Commissary 11 Dry storage only <br /> ❑ with Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only C1 Multiple Departments E3 Prepackaged Goods Only <br /> Vehicle Type ColSdcker# <br /> ❑ Mobile Food Vehicle----Make License# <br /> Registration# Vehicle Type Color. <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> to <br /> DAIRY PROGRAM (2000) / <br /> ❑ Grade B Dairy G,tt�/.t.. <br /> Milk Dispenser lumber of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy '� <br /> COPA [I State Facility Surcharge(2399) .- /�� <br /> H.4ZARDOUSWASTE PROGRAM(2200) ZZ�� Generate Peryea <br /> dHazardous Waste Generator--- <br /> ❑ Conditionally Exempt(CEJ <br /> Tiered Permitting Facility O PerDtiDBy-Rule Fixed Unit CA) ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use U¢T A and B forms <br /> HOUSING PROGRAM— (2400) ❑ Jail or Exempt Institution—Number of Units <br /> ❑ Hotelliviotel-------Number or Units <br /> Employee Housing(2700)Use Empl Yee H s.. �/LahD Camo Annlication form <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ UIC Site <br /> SITE MI�tOATION(2900) Cleanup <br /> C3 Environmental Assessment Q non-NPL/SEP Cleanup Site ❑PWS <br /> UST-CAP Site te C3RWQCB CleanupSite ❑ Water Quality Remediation Site <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(360❑0)Pool ❑ Spa Cl out of Service Pool/Spa <br /> Natural Bathing Area <br /> Number of PooWSpas at Facility <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT O BodyMETIC Pie eing(4 ROGRAM 0)(4100) <br /> El Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) <br /> LIQUID WASTE PROGRAM(4200) Capacity <br /> License# Vehicle# <br /> ❑ Pumper Vehicle-Registration# �-- ❑ Chemical Toilets—Number of Units�— <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Transfer Station C3 Ag/Cannery Waste Site [3 CIA Landfill Site <br /> ❑ Landfill ❑ Process/Recycle Facility <br /> ❑ Compost Facility ❑ Far'nr/Raneh Cleanup Site <br /> ❑ Waste Tire Facility p C1Dumpsters>20 cu yd—Number of Units <br /> C3 Refuse Vehicles-Number of Units <br /> MEDICAL WASTE PROGRAM(4500) C] Small Generator El Limited Hauler <br /> ❑ Primary Care <br /> ❑ Acute Care [ISkilled Nursing C1 Large Generator ' 10----❑ 1 l -60—❑ >60 generators <br /> ❑ Common Storage Facility — - <br /> C1 Transfer Station El Veterinary Clinic . <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM Milt Ph <br /> Day Ph_�— <br /> CONTACT PERSON ❑ Other FEE <br /> ❑ Surcharge FEE <br /> PROGRAM ELEMENT��� FEE�O jI to 3 ❑Food Handler <br /> L`ISPECTOR# pERMft VALID�O� INVOICE# <br /> ArIOtM PAID Date <br /> ❑ Check#�� 2.�_ <br /> ACCOIJNCING OFFICE <br /> ❑ Cash REVIEWED BY n <br />