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ykAN.4LOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION <br />I Facilitv ID Proaram Record ID I <br />Facility Address 17'Ll VUIV(ArV' 19P\TjSACV, CA <br />95376 <br />(Please check the appropriate description and specify size, number of units and <br />pertinent Information.) <br />FOOD PROGRAM (1606) <br />PERMIT V D <br />❑ Restaurant: Seating CapacitySquare Footage <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ wlMeat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit— Make Vehicle Type <br />Color <br />Registration# License# <br />Sticker# <br />❑ Temporary Food Facility —Dates of operation from to <br />Ice Plant P.Produce Stand <br />❑ Special Event. -- Dates of operation from to <br />CFO ❑ A <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 />❑ CalARP 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 USTA and forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotelil l—Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Houslnp/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ---Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />(4100) <br />❑ Kennel <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacilitySingle Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehlcleRegistration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (a of units) ❑ Dumpsters> 20 cu yd la or units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON Mnh it -Rn -m �yv1'SR.-7d- #-Day Ph ANight Ph <br />PROGRAM ELEMENTIWV-) FEER <br />❑ Surcharge FE <br />11 Other FEE <br />INSPECTOR# <br />PERMIT V D <br />w� <br />w IO ld0Food <br />Her <br />AmOUNTPN <br />Date <br />INVOICE# <br />.❑f�Check# <br />BBCas <br />r-REVIEWEDBY <br />ACCOUNTINGOFFICE <br />8tB <br />48-02A0M <br />VTERFILER <br />O'. <br />123113 <br />RFc�wO <br />APR <br />SV?04 5 ?0?? <br />iyr,CFy yp 414r <br />