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SAN JOA,QUIN COUNTY EIWONMENTAL HEALTH DEPAR NT MASTERFILE RECORD INFORMATION FORM New EH Pro am at Existing Facili ❑New EH Pro am and New Facility Facili ED Program Record ID Facility Address —7L45 S. L S n G d 1e-,) il. L 1�� (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Commissary ❑Dry storage only ❑ with Food Preparation ❑Vending 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 ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HA,ARDOUS WASTE PROGRAM(2200) I 1�,—• Hazardous Waste Generator------------Tons Generated Per Year 7�K Y❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-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 UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Housinz1Labor Camn Annlication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water 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, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration#, License# Capacity • Vehicle# ❑ Pumper Yard 1 ❑ 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/Ranch 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-----112- 10-------❑ 11 -60------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form /� EME GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1�OlJ (, 0 LAJ Day Ph — Night Ph PROGRAM ELEMENT 2 2 2-D FEE G ❑ Surchar a FEE ❑ Other FEE INSPECTOR# 931 -1 PERMIT VALID 1 1112 to 31 ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 Masterfile Record Pink 10/6/2003