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SA JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Pro ram and New Facility Facility ID rACO2b,7 Z-- Program Record ID RDE4% /S-� 11 Facility Address -L (L_L. NETT tt bT MODES -M CR L 155525 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Re it Market --Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ obile Food Vehicle –Make Registration # Mobile Food Prep Unit-- Make Registration # ❑ Temporary Food Facility –Dates of operation from ❑ Special Event ---Dates of operation from DAIRY PROGRAM (2000) Vehicle Type _ License #_ Vehicle Type _ License # _ to to _ Color Sticker # _ Color _ Sticker # _ ❑ Ice Plant ❑ Produce Stand ❑CFO ❑A❑B ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit _ CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP 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) ❑ PER (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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLJSEP 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 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) ❑ Pumper VehicleRegistration # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles (#of units) Capacity Vehicle # ❑ Chemical Toilets ---Number of Units AY- ❑ Ag/Cannery Waste Site ❑ Slud' ��% ❑ Process/Recycle Facility ❑ CIA Land I EIDumpsters > 20 cu yd (# of units) 11f h FarrfgVlean Site MEDICAL WASTE PROGRAM (4500) %J - 2021 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Gene[ �t6� i'.Aitte$tHauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - F6fLT gtors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ,kEIVr CONTACT PERSON - Day Ph PROGRAM ELEMENT FE11Su INSPECTOR # PERMIT VALID ';V2312,1 t0 _ ❑ Check# AMOUNTPAID -T.— Date ❑ Cash Odj REVIEWED BY 1 k \A M ACCOUNTING OFFICE 48-02-034 1/23/13 Night Ph4.502 1'p 17 O'J ❑ Other FEE ❑ Food Handler INVOICE # .S.S. � Date MASTERFILE RECORD INFORMATION PINK