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$AN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility WNeW EH Program and New Facility Facility ID 2,�L2o Program Record ID EiL 15V1 Facility Address 44nq 14mlD lar Circler 55w cM C4 53 ? (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: YEs)4 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 Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event—Dates of operation from to ED CFO ❑ A J4 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: ❑ 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) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs r-I 11..-L.r...,..._d CL..r......T....1. Dr....r..... /I ICT\ HOnn% 1'-- IICT A -11 Ol...-.... u unuer yrumru owrayn IdrIK rrvyramr tua I l tcoW1 Vse Vii A d11U O 1 1 M ❑Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel---Number of Units ❑ Jailor Exempt Institution—Number of Units Employee Housing (2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 0 Environmental Assessment tl UST-CAP Site C Local HW Cleanup-Site 'PJ-NPL/SEP Cleanup Site ❑ 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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm------Maximum number of birds ❑ 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 Vehicle Registration# License#. Capacity Vehicle# ❑Pumper Yard O Package Treatment Pfant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ashfi E ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Land9 i MP' ❑ Refuse Vehicles(#of Units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ Farm/RaAn MEDICAL WASTE PROGRAM(4500) 4Pp ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator 1,1 Llnfkefi3ller ❑ Transfer Station 11 Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 1, -60 F �®�Ugen� PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicat/on Form yE9(T R0/y NCOU EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM HGFNTgLN7Y CONTACT PERSON CS ( ' f h CI Day Ph Night Ph-1W-� PROGRAM ELEMENT 1001 FEE � [ISurch r e FE ❑ Other FEE INSPECTORI PERMIT VALID 1/Z t0 3b ❑ Food Handier y ❑ Check1 rf AMOUNTPAID Date �5 22 INVOICE `� L✓ 3 11y Cash I REVIEWED BY ACCOUNTING OFFICE Date Z/ 48,02-034 C 1 '1 �-r� ^�� MASTERFI ECO INFORMATION PINK 1123113 11y L G