Laserfiche WebLink
SAN JOA COUNTY ENIVIRONMI{JNTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORIYIATION FORM <br /> rVNew EH Program at Existing Facility ❑New EIi Program and New Facility <br /> Facilif`H) Q bC�U Pro ram Record ID i �We 3 <br /> Facility Address o��Ai n fly q5a 05 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes El No El <br /> ElCommissary ❑ Dry storage only ❑ with Food Preparation ❑rending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Ychicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Mahe Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ElSpecial Event —Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Dead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' t <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 ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B fomry <br /> HOUSING PROGRAM(2400) <br /> ❑ I1otel/11Iote1 Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Ftmploy+ee IIoasinZaobor Camp Appfication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAroamental Assessment ❑UST-CAP Site ❑ Local IIW Cleanup Site• ElNPL/SEP Cleanup Site El UTC Site <br /> ElAbandoned HW Site Elnon-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑}Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle—Registration# License# Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ElLandfill ElTransfer Station El Ag/Cannery Waste Site El Sludge/Astr Site <br /> 614 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/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UscPFf'SrIID 46-02-003 BlacAppiicafiort Forst <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGiu,NtELENIENT— �_ IEE ❑ SurchargeFFE ❑ Other FEE <br /> INSPEC OR# 1 _— PEP.MIT VALID to ❑ Food Handler <br /> El ct«eck f Date I1NOICE It <br /> ❑ Cash Rr; IFVIFD BY L arJ rl ACcouNTlyac OFFICE — -- Date ` Z <br /> -- --� <br />