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' JOAQUIN COUNTY ENVIRON -ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD Ilv'FORMATION FORM <br /> 3 New EH Program at Eitisfing Facility []New EH Program and New Facility <br /> 'Facili •ID k ProamReeord lD <br /> Facility Address 1 =Ca' S q(p <br /> (Please(:heck the appropriate description and specify�number of snits and Pertinent info anon) <br /> FOOD PROGRAM(1600) <br /> D Restaurant: Seating Capacity Square Footage _ Food Handlers Course required:. YES D No <br /> D Commissary D Dry storage only D with Food Preparation DArending Machines Number of Units <br /> D Retail Markel Square footage D with Meat Market only D Multiple Departments ❑Prepackaged Goods Only <br /> D Mobile Food Yehicle Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> D Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> D Temporary Food Facility •Dates of operation fcorli - to O 1 int <br /> Special Event -Dates of operation from to ❑Prodace Stattd ; <br /> DAIRY PROGRAM(2000) <br /> 0 Grade A Dairy E3 Grade B Dairy ❑Milk Dispenser--dumber of Containers in Muh-Head Unit <br /> COPA ❑State Facility So (2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <br /> D Hazardous Waste Generator.- Tons Georated Per Year [ Recycle/Exempt System(2299 <br /> [3 CRT Offsite Handlers(221 s) D Silver Only(?m) D Appliance Recycle=(2117) <br /> Tiered Permitting Facility D Conditionally Authorized(CA) D Conditionally Exc i pt(CS) <br /> D Permit By4ule Fixed Unit Q Permit-By-Rule:Household Hazardous 1£asC <br /> ❑ABOYEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(USI)PROGRAM(2300)Use UST A and B forms <br /> lIOUSIme PROGRAM(2400) , <br /> D HotcllMotd Number of Units .D Jailor Exempt Institution---Number of Units <br /> bola$0051°6(2?00)Use mployep R'ousiwz Labor CAM ApaCraatiox Form <br /> SITE M{7IGATtON(2900) UNDERGROUND INJECT om CONTROL{3000) - <br /> D Environmental Assessment' D UST-CAP Site E7 Load HW Cleanup Site. E]NPLISEP Cleanup Site ❑UIC Site <br /> D Abandoned HW Site D nava-dPLSEP Cleanup Site 13 R'%YQCB Cleanup Site ©Water Quality Remediation Site <br /> HECRL1lTlONAL HEALTH PROGRAM(36M) <br /> Number of PooLs/Spas at Facility. 13 Pool E]Spa D Out of Service Peowspa E3 Nat"Bathing Area <br /> YEGTOR.CON ItOL PROGRAM(4000) <br /> Poultry Farm----4Ux mum w=ber of birds Q Kennel <br /> A OO BODY PIERCING PERMANENT C METIC PROGRAM(4100) <br /> Tattooing(4121) D Body Piet^cing(4120) E3 Permanent Cosmetics(4122) <br /> UID WASTE PROGRAM(4200) <br /> Pumper Ythicle-Registration# License# capacity Vehicle# <br /> ,0-.13 Pumper Yard E3 Package Treatment Plant• ❑Chemical Toilets NumbCx of Units <br /> SOLID WASTE PROGRAM(4400) <br /> Landfill D Transfer Station D Ag i Cannery'% ste site ❑Sludge/Ask Site <br /> E3 Waste Tire Facility E3 Compost Facility E3 Process/ReCycle Facility D C1A Landfill Site <br /> E3 Refuse Vehicles Number of Units D Diners>20 cu yd---lumber of Units ❑FarnManch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 13 Primary Crire ❑Acute Care ❑SimedNur-Ang D Large Generator O Small Generator 13 Limited hauler <br /> ID Transfer Station D Veterinary Clinic D Common Storage Facility D 2-10 E311-60---E)>60 generators <br /> PUSLlC WATER SYSTEM PROGRAM(4600)Use PWS EHD 44-02-003 Blue AMUeffilon Form t c_ <br /> EMERGENCY NoTtE emoN FDRTms FACILITY ANDIOR PROGRAM t"27 <br /> CONTACTPERSON g ACYL L 2�f'5 S Day Ph Night P <br /> PROGRAM ELEbimm FEE EI Surcharge FEE` ❑Other FEE <br /> IxsrEerorc# PERMFT VALID . to D Food handler <br /> 11 Checks AMOUNTPAID Bate _ havoicE <br /> C3 - >�wral BY AtQt `` Date <br /> :, n <br />