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IIFSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IL MASTERFII_E RECORD INFORMATION FORM ❑ New EH Program at Existing Facility __ _ Vey✓EH Program and New Facility [Facility ID 06q3 _ Program Record IU_ Facility Address 149Q)O L3 Scljyj4, R� j h�,� q5-377 (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 ❑ vv/Meat Market only ❑ Multiple Departs rents❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registratiotl# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation from_ to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1000) Number of chemicals: ❑ CaIARP Program E7 Prograrn 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ CE (2233, 2234 2235. 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee HousinglLahor Camp Application Form SITE r�ITIGATION (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 Fane-------Maximum number of birds ❑ Kennel TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4 100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) E7 Body Art-Temp Event Mobile Facility (4131) 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 ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (= unitsi ❑ Dumpsters > 20 cu yd #of u!rts• ❑ 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 ❑ 'I 1 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PVVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON ((��7 Day Ph Flight Ph PROGRAM ELEMENT "1` FEE 9:S ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 00() PERIAT VALID t0 ❑ Food Handler ❑ Check# AMOUNT PAID / ZD Date INVOICE#c� I� ❑ Cash RE_IEkYED BY Accoufj i ING OFFICE _- Date / a ,n'4 r 1=.STEFFILE i .;c 1--