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"i N JOAQUIN COUNTY E ,_ RONMENTAL HEALTH DEPAR ENT MASTERFILE RECORD INFORMATION FORM IS New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 41740DO 2-` Pro ram Record ID U 5:; �O�fig Facility Address 4x,9,00 Al. 40'41H4 (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: YES ❑ No El ❑ Commissary ❑ Dry storage only 11 with Food Preparation ❑Vending Machines--Number of Units ❑ Retail Market----Square footage ❑ with 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 ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade.A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) .. Tiered Permitting Facility-------------- 11 Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit=By-Rule Household Hazardous Waste. DAB OVEG ROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use USTA and B forms 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 El 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) ❑ Tattooing(4 12 1) ❑ Body Piercing.(4120) ❑ Permane.nt Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registration# License# Capacity Vehicle ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site 0 Sludge/Ash Site I)Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ENVIRONMENTAL HEALTH ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El FDEPARTMENT 2 NO LONGER PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E/fD 46-02-00.3 Blue Application Fon INSPECTS WASTE TIRE EMERGENCY NOTIFICATION FOR THIS FACILITY AND/O� FACILITIES. It is a State run CONTACT PERSON Day Ph program effective 7/1/2017. PROGRAM ELEMENT X79/0 FEE ❑ SurchalrgeFEE ❑ Other FEE INSPECTOR# -689 PERMITVALID 7I11D(a to -7Q/D-7 ❑ Food Handler ❑ Check# AMOUNT PAID / Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date I 41,11c) 48-02-034 Masterfile Record Pink (0/62003