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SAI JOAQUIN COUNTY RONMENTAL HEALTH DEPA NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> '.New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID tA 0O,024y Program Record ID 2vS 3(-)-7,- <br /> Facility Address RS <br /> AI <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> I-] Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No 13 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines Number of Units <br /> []'Retail Market---Square footage ❑ with 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 /> El Temporary Food Facility--Dates of operation from to 11 Ice Plant <br /> ❑ Special Event Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> 11 Grade A Dairy El Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge (2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) -------------El Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility -------------------El Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use UST A and S forms <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 ❑ UI.0 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 1-] Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> El Tattooing (4121) [1 Body Piercing (4120) C3 Permanent Cosmetics (4122) <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 /> El Landfill El Transfer Station Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> X.Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility Fl CIA Landfill Site <br /> ❑ Refuse Vehicles(#or Units) ❑ Dumpsters> 20 cu yd (#or Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> El Primary Care 13 Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Generator El Limited Hauler <br /> ElTransfer Station ElVeterinary Clinic ❑ Common Storage Facility El2- 10 El 11 -60 El >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> rINSP' ECTOR# <br /> ELEMENT LAgLAO FEE ❑ Surcharge FEE ❑ Other FEE <br /> �� PERMITVALID t0 ❑ Food Handler# AMOUNT PAID DateINVOICE# <br /> Cash REVIEWED BY ACCOUNTING OFFICE Date 3 O <br /> MASTERFILE RECORD INFORMATION PINK <br /> 48-02-034 <br /> 11/15/07 <br />