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LSANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Pro ram at Existing Facility ❑New EH Program and New Facilit <br /> Facility ID Program Record ID $s <br /> Facility Address 11 41 S • >AVII 06 S[ OIC6-W(D <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market--Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> kMobile Food Prep Unit--Make Vehicle Type NTIy-7 Log Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ <br /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)------->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility------> ❑ CA(2232) ❑ CE(2233,2234, 2235, 2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST)(2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm---.—Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicia <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of UnitsP�� <br /> SOLID WASTE PROGRAM (4400) F 1. <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgP,/Qs CRd7YEQ <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA L II' l�e <br /> ❑ Refuse Vehicles)#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Fdlgq/ nc i ezri &Site <br /> MEDICAL WASTE PROGRAM (4500) kt,�Z,j�VV,1R� QUW COU <br /> ❑ Primary Care 11 Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generatoi"LltlD;—�'�Q,�'�"V <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 gAlw; Tors <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue AppllCation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM r-��� f <br /> CONTACT PERSON C ��111G) (1 Lu Q• hV1�1f Ph 0 — Ip�}Jight Ph �W-0310 <br /> PROGRAM ELEMENTFEE ❑ Surcharge FEE ElOther FEE <br /> INSPECTOR# OG216q <br /> PERMITVALID t0 1 n I 11 Food Handler <br /> Vheck# AMOUNT PAID Date �l i-j INVOICE# g <br /> ash REVIEWED BY I ACCOUNTING OFFICE Date Z <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 <br />