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SA�'�' JOAQUIN COUNTY ENWONMENTAL HEALTH DEPART NT 6015 0 le�;5 MASTERFILE RECORD INFORMATION FORM . !_-' Zl oc'_'��' j 13 New EH Program at ExistingFacility New EH Pror ram and New Facility I v Facility 1D rA—-1 Program Record ID 4C S� V3 Facility" Address a0$�`� /A,/e4✓Y 1)r- --I/ .1 (Please Check the appropriate description and specify size,number of units and pertinent information.) 41�00 FOOD PROGRAM(1600) Q ElRestaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No 11 ❑ 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 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 Nlulti-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 CNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use LISTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee Housing(2700) Use Employee floasino/Lahor 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 IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB 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) 11 Poultry Farm -------Maximum number of birds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent 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 ElTransfer Station 11Ag/Cannery Waste Site 11Sludge/Ash Site XNN,;tste'l'ire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Itefuse Vehicles--Number of Units _ ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage 02- 10 2- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph Cl EL,I',I�IF;N"1' �� FEE ❑ Surcharge FEE ❑ Other FEE INSPECtott# DOT a PERMI'I'VALID to ❑ Food Handler ❑ rck= AMOIIN"I'PMD Date INVOICE# er ❑ Cash REVIEWED BY �12Lt�Z /�Sk ACCOUNTING OFFICE Date Masterfile Record Pink 4R_02-03-1