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*AN JDAQUIN COUNTY ONMENTAL HEALTH DEPA NT <br /> MASTERFILE RECORD INFORMATION FORM __ <br /> C Ness EH Program at Existing Facility — --___ ❑Ne«_EH Program and New Facility <br /> Facilitv ID FA C ODC) I S 7 Program Record ID <br /> FacilityAddress <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES No El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type I Color <br /> Registration# License r Sticker# <br /> ❑ Mobile Food Prep Unit -Make Vehicle T%pe Color <br /> Registration# 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 /> 13 Grade A Dairy ❑ Grade B Dairy El Milk Dispenser --Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/ 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 USTA and B forms <br /> HOUSING PROGRAM(2.300) <br /> ❑ Ilotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> EmploNee(lousing(2700) Use Employee HousinzlLabor Cantn Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ E:n%ironmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HNL'Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number cif fouls/Spas at FacihtN ❑ Pool C1 Spa C1 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm -------\Maximum number ofbirds <br /> El Kennel <br /> TATTOO. BODY PIE_RCIN_G. PERMANENTCOSMETIC PROGRAM.(4100) <br /> ❑ Tattooing(-3121) ❑ Body Piercing(4120) El Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C1 Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(1400) > <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> P Waste'Fire Fncility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Itcfusc N'chicics--Numhcrofllnils —__-- <br /> - ❑ I)umpslcrs>20 cu 1d----Numbcr of'U nils ❑ farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(400) <br /> El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> 11 Transfer Station El Veterinary Clinic El Common Storage Facility----C1 2- 10------- El l -60---- 11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM.(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM. <br /> CONTACT PERSON Day Ph Night Ph , <br /> PItDGRAJI ELEMENT1�, L-I_ q C, FEE ❑ Surcharge FEE ElOther FEE <br /> I;�sl ec rolt# 00(L,() PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AOUNT PAID Date / INVOICE <br /> M # <br /> 11 Cash REVIEWED BV' r� � ���C'�' ACCOUNTING OFFICE DatO G �t �CS <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6.2O()3 <br />