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a <br /> II , GAN jOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> j± MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> cility ID E]I& D(-_�-ac Sg O Program Record ID i�z 53 S" ZZ_ <br /> -acility Address _T�i,,-c 1A . <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 ❑ <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 Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit Make Vehicle Type 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 /> ❑ 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) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) -------------11 Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility -------------------1:1 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 forms <br /> HOUSING PROGRAM (2400) <br /> '-lotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> doyee Housing (2700) Use Employee Housing/Labor Camp Application Fonn <br /> E MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP 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 Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm ------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY 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 /> P Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of Units) ❑ Dumpsters> 20 cu yd (#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 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 /> `GRAM ELEMENT '�—j FEE Cly ❑ Surcharge FEE ❑ Other FEE <br /> _CTOR# 7 PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY <br /> Zel �tACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />