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SAN;1D <br /> QUIN COUNTY ENVIRONMENTAL IJEALTfl DE,PARTAIENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New gram at Existin Facility ❑New Eli Program and New Facility <br /> Facilit = S Pro ram Record ID _ <br /> facility Address �� Ol N SoLu��g 2-� <br /> (Please Check the appropriate description and specify size.number of units and pertinent information.) <br /> rOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation El Vending Machines—Number of Units <br /> [JRetail 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 Color <br /> Registration it License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ 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) 4 <br /> ❑ hazardous Waste Generator--- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Pernut-By-Rule Household Hazardous Waste <br /> ❑SABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> HUNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> OUSING PROGRAM(2400) <br /> ❑ Hotentotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use F,mployee floasingyEabor Camp Application Form <br /> SITE MITIGATION(2940) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑ Local HIV Cleanup Site, ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLISEP 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 PoollSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO 13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <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 /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number 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 ❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIf,SFFfD 46-V2-003 BlacApplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGR.AAI ELEMENT W740 FEE 10 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 2(D-Aa PEPMMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY �6 1p ACCOUNTING OFFICE / Date <br />