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&AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proqram at Existing Facilitv ❑New EH Program and New Facility <br />RecordlD <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />X 11 I15ll"214wed <br />LO LZ•' C��� <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 />❑ etail Market—Square footage ❑ w/Meat Market only 11 Multiple Departments El Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type 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 />❑ CaIARP 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 />❑ Hotef/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 Vehicl <br />El Pumper Yard ❑ Package Treatment Plant 1:1 Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400)p�y�,,�,, <br />11 Landfill El Transfer Station <br />11Ag/Cannery Waste Site <br />Ve® <br />ElSludgefF(3v <br />El Waste Tire Facility ❑ Compost Facility <br />ElProcess/Recycle Facility <br />[ICI&AW98fill Sit 7�?1 <br />❑ Refuse Vehicles (#of units) <br />❑ Dumpsters > 20 cu yd (# of units) <br />❑ Fir Sup Site <br />MEDICAL WASTE PROGRAM (4500) <br />lPrimary Care El Acute Care El Skilled <br />TND p'qq�u�fiNTgL 7y <br />Nursing El Large Generator 11 Small Generator ElLimiteif <br />❑ Transfer Station ❑ Veterinary Clinic <br />❑ Common Storage Facility ❑ 2 - 10 <br />❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM (q%;) „175 -3IJ,9 <br />n <br />CONTACT PERSON )(jY22 Rl1 Cs-I�JYCr�L <br />CYay"Rh <br />Night Ph <br />PROGRAM ELEMENTI �pL FEE3 ❑ Surchar e FEE <br />❑ Other FEE <br />INSPECTOR# PERMIT VALID <br />1 t0 I2 31 2022 <br />❑ Food Handler <br />❑ Check# AMOUNT PAID 11��J <br />Date <br />INVOICE# 2 <br />❑ Cash CaM REVIEWED BY <br />ACCOUNTING OFFICE <br />Date %21 <br />48-02-034 _ _ _ <br />1/2 311 <br />1123113 `�1`�,�,jy' <br />1 y, , <br />1'M� 1l5 „•-yam <br />` `��J 1� <br />MASTERFILE RECORD I FORMATION PINK <br />