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�.t` JOAQUIN iftONMENTAL HEALTH DEPAT MASTERFILE RECORD INFORMATION FORM ER -blew EH Program at Existing Facility ❑New EH Program and New Facility [Facility ID ODE) 3�f Program Record ID �D So2a 3�g Facility Address (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 ❑ ❑ Commissary ❑ Dry storage only ❑ 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 Registration # ❑ Mobile Food Prep Unit --Make Registration # ❑ Temporary Food Facility -----Dates of operation from ❑ Special Event --Dates of operation from Vehicle Type License # Vehicle Type License # 2 _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ 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------------------ ❑ 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 UST A 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 ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm --------Maximum number of birds_ TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration #_ ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity_ ❑ Chemical Toilets SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site M -Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Kennel ❑ Permanent Cosmetics (4122) Vehicle # Number of Units ❑ Sludge/Ash Site ❑ CIA Landfill Site ❑ 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 ----- 112-10 ------- ❑ 11-60 ------ 1:1 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Day Ph Night Ph PROGRAM ELEMENT FEE _ INSPECTOR # 'D "R7 PERMIT VALID AMOUNT PAID tet/ Date ❑ Surcharge FEE ❑ Other FEE to ❑ Check # ❑ Cash 48-02-034 1 n is n nnl REVIEWED BY ACCOUNTING OFFICE ❑ Food Handler INVOICE # (�J Date Masterfile Record Pink