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SA ,QUIN CO ':ITY ENVIRONMENTAL HEALTH DEPARTMENT M_A£ ERFILE RECORD INFORMATION FOM ❑ New I 'rograrn at Existin Facility New EH Program and New Facility Facilit �� Program Record ID Facilit Address�0 45 (Please c: *the appropriate scription and specify size, number of units and pertinent information.) FOOD PR r1AMI(1600) ❑ Resta nt: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Comr :ary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retai, rket----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mpbil god Vehicle--Mak , Vehicle Type Color Registration 4 License It Sticker# Mobil 1od Prep Unit_ Make VehIile Type Color Registration 4 License# y Sticker# ❑ Temp ry Food Facility--')ates of operation from to ❑ Ice Plant ❑ Speci -vent Dates of op( -ation from to ❑ Produce Stand DAIRY PF RAM (2000) ❑ Grade Dairy Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA State Facility Sun large (2399) HAZA OUS WASTE PRC GRAM(2200) E azardous Waste c enerator------------Tons Generated Per Year ❑ Recycle/Exempt System (2>99) ❑ CRT Offsite Handler; (2218) -------------El Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Fac "y -------------------El Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ BOVEGROUND STORAGE TANK FACILITY(AST) (2390) Number of AST tdDERGROUND S FORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING I OG RAM(2400) ❑ Hotell tel------Number o` lnils ❑ Jail or Exempt Institution ----Number of Units Employee using(2700) Usc_ np/ogee Housing/Labor Camp Application Form SITE MITI( "ION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Envir( cental Assessme ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abanc ed HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIO JAL HEALTH PROD AM (3600) Number of fools/Spas at Facili ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CC ITROL PROGRAM(1000) ❑ Poultry "arm-------Maximum number of birds ❑ K+%YMENT TATTOO,B' JY PIERCING PERT%ANENT COSMETIC PROGRAM (4100) RECF�IIV�D ElEl1:1Tattooi (,1121) Body Piercing (4120) Permanent Cosmetics l4 2 LIQUID WA -E PROGRAM(420` 1 SEP 0 5 2099 ❑ Pumpe ✓chicleRegistratic 1/ License# Capacity Vehicle It ❑ Pumpe! Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of tSrMJOAQUIN COUNTY ENVIRONMENTAL SOLID WAS E PROGRAM(4400( HEALTH DEPARTMENT ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tare Facility ❑ C:ompost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (n of Units) _ ❑ Dumpsters>20 cu yd(#or Units) ❑ Farm/Ranch Cleanup Site MEDICAL W,',STE PROGRAM(4;;30) ❑ Primary Care ❑ Acutc Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfe Station ❑ Veter nary Clinic ❑ Common Storage Facility 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WA t='t SYSTEM PROGI AM(4600) Use PWS EHD 46-02-003 Blue Application Form J f EMERGENCY NOTIFICATION FOR THIS FAC LITY AND/OR PROGRAM CON:-AC- 'ERSON Day Ph -�(o- �q Night Ph '2-01- PROGRA, LL'�IENT FE ❑ Surchar a FEE 11 Other FEE INSPECTQI2 _ 2� 'ERMIT VALID S ( t0 1 ❑ Food Handler ❑Ao IsCOUNT PAID 23 2- Date INVOICE# � ❑ Cash RGVIEWED BY a ACCOUNTING OFFICE Date 48-02-034 �� ✓ MASTERFILE RECORD INFORMATION PINK 11/15/07 TTT