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I PS-AN JOAQ_UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT p�Y w,� MASTERFILE RECORD INFORMATION. FORM A'LC�� ❑ New EH Program at Existin Facili Egg lew EH Pro ram and New Facili Facilit ID Pro ram RecordLID, Sf'0 P/�Facility Address �� r /r� 5 � I�I1 (Please check the appropriate description and specify size, number of units and pertinent information.) ��D;Oft,4d Ek IJ Ty FOOD PROGRAM(1600) �TM�jyT ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes,E P No ❑ ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration# License# Sticker# ❑:Mobile F,00d.Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ;B'.CFO -97A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Cohtainers in Multi-Head Unit CUPA E ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Progr�m 3 Facility ❑ Hazardous Waste Generator(2200)-------->-Tons Generated Per Year ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PSR HHW(2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ U,ndergrQund.Storage Tank Program (UST) (2300) Use USIA and B forms j u Ottier CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SE?Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) I 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) D',Bbgy'Ait.eractitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art emp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) III ❑ Pumper Vehicle Registration# License# Capacity I Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site i ❑ 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) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON I-Q/kUj1 A � S t/(n DayPh Dight Ph 1,0j CI l_ L�tri PROGRAM ELEM NT o� i9 FEE _C U ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID i t0 c7 ,I11:1Food Handler 11Check# J)el�tAMOUNT PAI �� -O_ Date L�!�KIZ0_ IIINVOICE# ❑ Cash REVIEWED BY LA S. ACCOUNTING OFFICE Date 034 1 � STERFtLE RECORD INFORMATION PINK 112311 1!23173 !I