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}� �11 SA JOAQUIN COUNTY EN �ONMENTAL HEALTH DEPART'' —'�1T o aCrt-e6 MASTERFILE REs-ORD INFORMATION FORIM _� CA New EH Program at ExistingFacility ❑\e« EH Program and New Facility �60 FacilitID —A 0003?] p Program Record ID 14R c� S SS Facility Address --l�3 - -- E St (Please Check the appropriate description and specify size,number of units and pertinent information.) J 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 ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicl,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 Multi-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------------------13 Conditional]% .-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 UNDERGROUND STORAGE TANK(UST)PROGRAM(23001 Use USTA and B forms HOUSING PROGRAM(2400) ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNN Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW 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) ❑ Poultry Farm -------Maximum number of birds ❑ 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 ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu Nd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(400) ❑ Primary Care El Acute Care ❑ Skilled Nursing El Large Generator El Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02- 10- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PRS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Da% Ph Night Ph PROGRAM EI,ENIE:NTy7y0 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 00(po PERMIT VALID to ❑ Food Handler ❑ Check;; AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY J_e 0) 0(p 0S .-ACCOUNTING 0=='CE Date 0� 48-02-034 Masterfile Record Pink 10/6/2003