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S2:N JOAQUIN COL-NTN ENVIRONMENTAL HEALTH DEPARTINIENT NIASTERFILE R RD INFORN-IATION FORNI ❑ New EH Pro ram at Existing Facility ew EH Pro ram and New Facility Facility ID Pro ram Record IDliJ� Facility Address / D Ac,, �.-L=z<_ (Please Check the appropriate description and specify size,num er of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Cap-acity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dry stora_e only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square foo:aee ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----1tae Vehicle Type Color Registration = License# Sticker# ❑ Mobile Food Prep Unit--11 ::e Vchicle"Type Color Registration = License 11 Sticker# ❑ Temporary Food Facilit}-----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-l-lead 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 Facilit}---------- ❑ 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 [IST A and B forms HOUSING PROGRAM(2400 ❑ HotelIMotel-------Number o`L:nits ❑ Jail or Exempt Institution------Number of Units Employee Housing(2700) Use Emplot•ee Honsinp/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 Facillr: ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm- Maxim.=number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM "200) ❑ Pumper Vehicle--Registrat:o,i= License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(-00) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of L'nits ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------1:1 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT LLc7 FEE _ ❑ Surcharge FEE ❑ Other FEE LLjINSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check# .-AMOUNT PAID DateINVOICE# ElCash REVIEWED 31' ACCOUNTING OFFICE �\,v��` Date 48-02-034 Masterfile Record Pink 11/18/03