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SAN JO QW1 C OUN o IVgV0RONMEN T AL HLEA LTH DEPA ENT <br />IiMIAS T ERFILE RECORD INFORMATION FORM <br />M_New EH Program at Existing Facility ❑New EH Program and New Facilitv <br />Facilitv ID i7 <br />Program Record ID <br />Facility Address JU, <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <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 _ <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event Dates of operation from to <br />Color <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ 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) -------------❑ 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 USIA and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee HousinglLabor 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 ❑ UIC 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 <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />KWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 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 />PROGRAM ELEMENT �J 7�''V& FEE_ <br />INSPECTOR#PERMITVALID <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWED BY <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE#- <br />Date c� / <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />