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AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existinq Facility XNew EH Program and New Facility <br /> Facility 1 6 Program Record ID <br /> Facility Address _2_42. pd <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM (iGOO) <br /> [] Restaurant: Seating Capacity______ Square Footage Food Handlers Course required: vso [] No [] <br /> El Commissary [] Dry storage only [] with Food Preparation []VendingMachines NomberofUnits <br /> [] Retail Market----Oquarefootage [] w/Meo1Market only [] Multiple Doparunento[] Prepackaged—Goods Only <br /> -------- <br /> LJ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# Licenoo# Sticker <br /> [] Mobile Food Prep Unit--Mahe Vehicle Type ���------ Color <br /> Registration# Lioonoe# Stickel # <br /> El Temporary Food Facility --Dates of operation from to [] 1oo Plant [] Produce Stand <br /> [] <br /> Special Event 'D teomfoponahon hn m to [] CFO [] A [] B <br /> (2000)DAIRY PROGRAM <br /> [] Grade ADairy [] Grade B Dairy [] Milk Dinpenaer'NumberofCmntaine,n in Mo|b'Head Unit_____ <br /> CUPA <br /> -Hazardous Materials Business Plan (1Q0O) Numbn,ofchemicals: � <br /> LJ Ca|ARP Program [] Program 1 Facility [] Program 2 Facility [] Program 5 Facility <br /> [] Hazardous YVustn Generator(2200)----------� Tons Generated Pei Yea <br /> [] Tiered Permitting FadUty--'--> [] CA (2232) [] CE (2283 2234 2235. 2237) [] PBR (.223|) [] P8R HHVY (2236) <br /> [] Aboveground Storage Tank Facility (AST) (2000) Number cfAGTa_________ <br /> [] Underground Storage Tank Program (UST) (2300) Use <br /> [] Other CUPA Program <br /> HOUSING PROGRAM (24OU) <br /> [] Hotel/Motel------NumberofUnits [] Jail o, Exempt Institution ----Number nfUnits <br /> _________ <br /> Employee Housing (27OO) Use Employee HousinglLabor Camp Application Fnnn <br /> SITE MITIGATION (2900) OOO) <br /> [] <br /> Environmental Assessment [] U3T'CAPSito [] Local HYVCleanup Site [] NPL/SEP Cleanup Site [] U|C site <br /> [] Abandoned HVVSite [] non-NPL/SEP Cleanup Site [] RVVOCB Cleanup Site [] Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3O0n) <br /> NumberofPools/Spas atFacility El Pool [] Spa [] Out ofService Pool/Spa [] Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (40OO) <br /> [] Poultry Form-------Maximumnumber ofbirds El Kennel <br /> TATTOO, BODY PIERCING.PERMANENT COSMETIC PROGRAM (410O` <br /> LJBody Art Practitioner Reg (4110) [] Mechanical DSPSNotification (4115) [] Body Art Facility-Single Use (412O� <br /> [] Body Art Facility-Sterilization (4121) [] Body ArtTompEventCu'ood (413O) [] Body Art-TompEvent Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM (42OU) <br /> Ll PLI111perVeiiic]eRegisti-atioii# License# Capacity VehkJe#_________ <br /> [] PumporYaod [] Package Treatment Plant [] Chemica|Toilets ----Number ofUnits <br /> SOLID WASTE PROGRAM (4400) <br /> El Landfill [] Transfer Station [] Ag/Cannery Waste Site [] Sludge/Ash Site <br /> LJ Waste Tire Facility [] Compost Facility [] Process/Recycle Facility [] CIA Landfill She <br /> [] Refuse Vehicles (=a'u""^) [] Dumpstern> 2Oouyd ',�c,fuo'ts, [] Fann/RanohCleanup Site <br /> MEDICAL WASTE PROGRAM (45O0) <br /> [] Primary Care 1:1 Acute Cam [] Skilled Nursing [] Large Generator [] Sn`a|| Generator [] Limited Hauler . <br /> [] Transfer Station [] Veterinary Clinic [] Common Storage Facility [] 2 10 [] 11 - 60 [] > ODgenerators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use Fo/n/ <br /> EMERGEtqcy NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br />