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i 9AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F RM �F MFNr ❑ New EH Program at Existing Facili ew EH Program and New acili C��VcO Facilit ID 00)-& 5 1 Pro ram Reco>dtlD,. DS SFp 18 C Facility Address S kfDr) ti you (Please check the appropriate description and specify size, number of units and pertinent inform'ation.) ft;L41D0Ep"C0U� FOOD PROGRAM(1600) �r�TpMENr ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES p Nc ❑ ❑ Commissary ❑ Dry storage 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# re, 7 obite;Fgad:PrepUnit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to 1 11 Ice Plant 11 Produce Stand ❑ Special Event---Dates of operation from to ;F?�FO IFA ❑ B DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA 11 Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 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 0 1 de'ug.M Vtorage Tank Program (UST)(2300) Use UST A and B forms j u Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution)----Number of Units Employee Housing(2700) Use Emaloyes Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 Farmn------Maximum number of birds ❑ Kennel TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) I I Qo8�j', i ?tactit10n`er Reg (4110) ❑ Mechanical DSPS Notification(4115) 11 Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art�Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ 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 ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 1 ❑ CIA Landfill Site ❑ Refuse Vehicles I#of units) ❑ Dumpsters>20 cu yd (#of Units) T( ❑ 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 I❑ 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 A Day PhAta-SLS 211D� Might Ph (0s PROGRAM ELEMENT FEE ✓ ❑ Surchar FEE ,❑ Other FEE INSPECTOR# ' $i PERMIT VALI `I t0 2 ❑ Food Handier , //� ❑ Check# AMOUNT PAI s- Date ` 2.� (INVOICE#p f 6 ❑ Cash REVIEWED BY �. ACCOUNTING OFFICE I, Date ! �- 1/23/1034 �, . n I � Mp'STERFILE R CORD NFORMATION PINK 1/23/13 /L/r/t111'�f�