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TSAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID Program Record ID Facility AddressIsl I"10keltiInneIX Loc' C-14 GjSZcI( U (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity_acit V Y_ Square Footage Food Handlers Course required: YEs j i No ❑ ❑ 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 Vehicle 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 ❑ AAB 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: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------> Tons Generated Per Year ❑ Tiered Permitting Facility------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ 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 ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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) ❑ Poultry Farm------Maximum number of birds ❑ Kennel 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) ,�p�`�,'� ❑ Pumper Vehicle Registration# License# Ca 0'�•�'®® Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical I�t� 7 blbe of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site a�,1 1 El Waste dge/Ash Site Waste Tire Facility Compost Facility ElProcess/Recycle Facility 'pkAlLandfill Site ElRefuse Vehicles O orunits) L1Dumpsters> 20 cu yd (*or u� y,1OPP NPS ar/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) �Ecp��,�.�0 ❑ 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 �1 /� CONTACT PERSON 9�u-(G, U( LkCi5 (\ 1 Day Ph-R61'3 Night Ph ;C09 y-ga-��a3 EINSPE6TOR RAM ELEMENT./ �% / FEE %.� G� ❑ Surcharge FEE El Other FEE # IU' c�- PERMITVALID t0 1 I ❑ Food Handler ck#ZnS�J AMOu TPAID �12.� Date lZ l`Z t7 INVOICE# h REVIEWED1 ACCOUNTING OFFICE Date 48-02-034 ' 1/23/13 MASTERFILE RECORD INFORMATION PINK