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SAL. N J'OAQUIN COUNTY IRONME�VTAL HEALTH, ©EPA ENT PAY NT` MASTERFILE RECORD INFORMATION FOR�h � �? COVE ❑ New EH Program at Existing Facility rIZNew EH Progrartl and New FacilitNOV 5 y i � Facilit ID Program Record ID 1 N ,IOAQUIN.cPUNTY Facility Address 63E Al.. r t I rvv:ac)MEM AL:� 1-11=Al I H O PAOMENT (Please check the appropriate description and specify size, number of units and FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Hatliheii d6urse required: YES ❑ No f-1 ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending MiWhes Numbe6of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile f=ood Vehicle -Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker#. El Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand` ❑'Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM(2000) ❑ Grade A`Dairy ❑ Grade B Dairy' ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: El g g g El Program 3 Facility CaIARP Program ❑ Pro ram 1 Facility ❑ Program 2 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility- -----> ❑.CA(2232) ❑ CE (2233, 2234,2235, 2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs,_ ❑ Underground Storage Tank Program (UST) (2300) Use USS` form$' ❑Other CUPA Program HOUSING PROGRAM(2400) , ❑ Hotel/Motel------Number of Units 13 Jail or `ern t inetitutlmn•�.¢Aumberof-Vnits Employee Housing (2700) Use Employee Hou sin g1LaborCatlW4AbplicatiFit SITE MITIGATION (2900) UNDERGROUND INJECT160dQNiT2 L t�400�j ❑ Environmental Assessment El UST-CAP Site ❑ Local HW Cleanup Site Cl N"PList Cleanup Site ❑ UIC Site 1:1 Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup"'Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC`PROGRAM (4100) 1 Body Art Practitioner Reg (4110) 13Mechanical DSPS Notification (4115) '" (3ody Art Feaility-Single Use (4120) ❑',pody Art Facility-Sterilization (4121) ;❑ Bony Art Temp Event Co-ord (4130) t1ffddy Art-Ten's I veotMobile Facility(4131) LI I T.WASTE PROGRAM (4200) ❑ Pu per 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(#of Units) ❑ Dumpsters>20 cu yd (#of units), ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) 13 Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic 1771 Common Storage Facility ❑ 2 - 10 ❑`11 -60 ❑ >60.gellerators ; PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fomi EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT N)10 1;L t-A FEE 1A5A-A ❑ Surcharge FEE ❑ Other FETE INSPECTOR# PERMIT VALID t0 ❑ Food Handler 0 Check# AMOUNT PAID Date *f INVOICE# El-Cash REVIEWED BY ll, ° ACCOUNTING OFFICE Date? 48-02-034 j 1 MASTERFILE RECORD INFORMATION PINK '