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AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facilit F a c i I i!y ID ow I Program Record Facility Address 7AEFawa s (Please check the appropriate description and specify RUI;number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ 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 ❑ M He Food Vehicle–Make Vehicle Type Color Registration# License# Sticker# Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# 1LOSQ Sticker# ❑ 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: ❑ 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 ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution ---Number of Units Employee Housing (2700) Use Employee 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-NPUSEP 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 Farm------Maximum number of birds ❑ Kennel TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner 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-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) PAYMENT ❑ Pumper Vehicle Registration# License# Capacity vEDcle# ❑ Pumper Yard ❑ Package Treatment Plant 13Chemical Toilets--- uWer of Units SOLID WASTE PROGRAM (4400) APR 2 0 2021 ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludgef h Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility SAN JOA.Qg1,W1Cr as �ll Site ❑ Refuse Vehicles(#of units) ❑ Dum sters>20 cu d #of Units ENV' p y ( _ HEAI=TH fgpiitNlgltTch 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 ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FAC ITY AND/OR PROGRAM CONTACT PERSON /' Day Ph Night Ph PROGRAM ELEMENT_ FE 9- O ❑ Surcharge F ❑ Other FEE INSPECTOR# 3,3101 PERMITVALID IY1201Z to f � ❑ Food Handler ElCheck# AMOUNT PAID T Z 3q — Date 7iD Zo 7i / INVOICE# Cash REVIEWEDBY ACCOUNTING OFFICE at /4M2-034 MASTERFILE RECORD INFORMATION PINK 1123113