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S'AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility I:T-=.III1] Facility Ad (Please check the appropriale description and specify size, number of units and pertinent information,) FOODPROGRAM (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 ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License #_ Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type. Registration # License # ❑ Temporary Food Facility —Dates of operation from ❑ Special Event ---Dates of operation from to to IN _ Color Sticker # _ ❑ Ice Plant ❑ Produce Stand CFO IKIA❑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 ❑ Hazardous Waste Generator (2200)--- ------ >-Tons Generated Per Year ❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) 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 ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm ----Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa mi1ni18ligIng Area TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # ❑ Pumper Yard ❑ Package Treatment Plant SOLIDWASTE PROGRAM (4400) �ECEIVED Kennel AUG 19 2021 Body Art Facility-SM]Jlttf4�D A&PTy Body Art -Temp EveEWRI1 Wj{4131) H�yTH DEPAR Capacity Vehicle # ❑ Chemical Toilets ---Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ 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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PROGRAM ELEMENT ❑ Check ❑ Cash 48-02-034 1/23/13 C FEE PERMIT VAL AMOUNT PAID gf L J S — Day Ph ❑ Surcharge FEE 1:1 Other FEE to �y 1 / 2 Z ElFood Handler O Date ��- � i/D 2�1 INVOICE # V REVIEWED BY ACCOUNTING OFFICE eprkk� 13 03 9 L ✓-'j I Date MASTERFILE RECORD 0