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'AN JOAQUIN COUNTY ENVONMENTAL HEALTH DEPARTNT—NT MASTERFILE RLQ ORD INFORMATION FORM _ (�❑' New Ell Program at Existing Facility ❑New EH Program and New Facility cilif} ID fikDVID311 Pro rain Record ID p120 S3&L If3 , ,edit}' Address ZI/ 0 o'U (Please Check the appropriate description and specify size,number of units and pertinent information) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Squarc Footage Food Ilandlers Course required: YEs❑ No ❑ ❑ Commissary ❑ Drystorage only ❑ xrith Food Preparation ❑Fending Machines—Number of Units ❑ Retail Market--Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type' Color Registration# License# Sticker#.. ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility----Dates of operation from to ❑ Iee Plant ❑ Special Event —Dates of operation from to ❑ Produce Staud DAIRY PROGRAM (2040) ❑Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) El Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Peiinit-By-Rule Fixed Unit ❑Permit-By-Rule household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forms HOUSING PROGRAM(2400) notd'Motel Number of Units ❑Jail or Exempt Institution Number of Units toy"IIousing(2700)Use Employee HorrsinzlLabor Camp Application Form biTE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) ❑ Environmental Assessment ❑ UST-CAI'Site ❑Local llNV Cleanup Site, ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IiW Site ❑ non-NPUSEP Cleanup Site ❑RIVQCB Cleanup Site ❑ 'Pater 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,13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) 13 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 yd----Number of Units ❑Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2- 10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use P11:SEIID 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph r )GRAM ELEMENT -1 -7(10 FEE CI ❑ Surcharge FEE ❑ Other FEE j -iSPECTOR# PERMIT VALID . to ❑Food Handler ❑ C ,:,-k# I AMOUNT PAID (2f - Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE