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SAN .10-AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility EINew EH Program and New Facility <br />PROGRAM ELEMENT -2:2-20 FEE 2_4 er <br />INSPECTOR # PERMIT VALID <br />p'S-urcharge FEE qg D Other FEE <br />to 0 Food Handler <br />Li Check # A OUNT PAID Date I IL >0 INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE Date --1•1/ / 22) <br />48-02-034 MASTERFILE RECORD INFORMATION PINK 1123:13 <br />1 Facility ID A Dbl OS Program Record ID FRb6-t-1-5 AL') <br />Facility Address iia7Dci Pea_ L4Sjo elc-j- o 7) Cci <br />(Please check 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 0 No 0 <br />Commissary 0 Dry storage only El with Food Preparation OVending Machines Number of Units <br />0 Retail Market----Square footage 0 w/Meat Market only El Multiple Departments El Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />131 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to El Ice Plant [3 Produce,Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy El Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />Cu PA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility -2<tztazardous Waste Generator (2200) > Tons Generated Per Year -Z 1V1 <br />Tiered Permitting Facility > CI CA (2232) LI CE (2233, 2234, 2235, 2237) LI PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units LI Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site LI Local HW Cleanup Site 0 NPL/SEP Cleanup Site LI uic Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool 0 Spa 1=1 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station LI Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility El CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station El Veterinary Clinic El Common Storage Facility 0 2 - 10 0 11 - 60 0 > 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 /> Day Ph Night Ph CONTACT PERSON