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SfJOAQUINN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 141 New EH Program at Existing Facility ❑New EH Program and New Facility [Facility ID �5cnL Program Record ID -7 I S% Facility Address RETE SND AUGZ3 2011 (Please check the appropriate description and specify size, number of units and pertinent Information.) " r MEN? FOOD PROGRAM (1600) ❑ Restaurant Seating Capacity Square Footage Food Handlers Course required: YEs)d 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 # ❑ Mobile Food Prep Unit- Make Registration # ❑ Temporary Food Facility -Dates of operation from ❑ Special Event—Dates of operation from DAIRY PROGRAM (2000) Produce Stand ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ C2IARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) —> -Tons Generated Per Year ❑ Tiered Permltdng 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) Cl Hotel/Motel --Number of Units ❑ Jall 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 She ❑ 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel I TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacllltySingle Use (4120) ❑ Body Art Faclllty-Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Tamp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehlcleRegistration# License# Capacity 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 ❑ CIA L-andflll Site ❑ Refuse Vehicles is or Units) ❑ Dumpsters > 20 cu yd (u of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped 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 FEE Day Ph _ ❑ Su INSPECTOR# ,i, PERMIT VALID '77/ 2� t0, ❑ Check # AMOUNT PAID Date ❑ Cash REVIEWED BY OFFICE V1 ❑ Other FEE ❑ Food Handler INVOICE # Date `t 312-1 48e2334 /SO S�-��_� MASItlihllt RECORD INFORMATION PINK 123!13 ��/%��r/rl License # Sticker # Vehicle Type Color License # Sticker # to EI off Plant ❑ to CFO A❑B Produce Stand ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ C2IARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) —> -Tons Generated Per Year ❑ Tiered Permltdng 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) Cl Hotel/Motel --Number of Units ❑ Jall 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 She ❑ 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel I TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacllltySingle Use (4120) ❑ Body Art Faclllty-Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Tamp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehlcleRegistration# License# Capacity 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 ❑ CIA L-andflll Site ❑ Refuse Vehicles is or Units) ❑ Dumpsters > 20 cu yd (u of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped 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 FEE Day Ph _ ❑ Su INSPECTOR# ,i, PERMIT VALID '77/ 2� t0, ❑ Check # AMOUNT PAID Date ❑ Cash REVIEWED BY OFFICE V1 ❑ Other FEE ❑ Food Handler INVOICE # Date `t 312-1 48e2334 /SO S�-��_� MASItlihllt RECORD INFORMATION PINK 123!13 ��/%��r/rl