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JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existinq Facilitv ID New EH Proqram and New Facilitv II Facilitv ID I/9-70'4 G -f-lo- / I Proqram Record ID i LO S 4' TIS I I Facility Address I - (Please check the appropriate description and specify size, number of unit: FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Mobile 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) ❑ Grade A Dairy ❑ Grade B Dairy and pertinent information.) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Vehicle Type _ License # Vehicle Type License # to to A _ Color Sticker # Color Sticker # _ ❑ Ice Plant ❑ Produce Stand CFO ElA❑B ❑ 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 ❑ 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-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 _ TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) JUN 0 8 2022 ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Us W20) ❑ Body Art Facility -Sterilization (4121) 11 Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Even rlt b llg fgcility (4131) HEALDEPAR ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area PAYMENT fl%ftLrD LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets —Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11-6o ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM GUN I ACI PLKSUN ordud owuL uay rn 0U0 -440-00U4 IWgnI Yn OUO-44a-0004 PROGRAM ELEMENT ►!9 6Z FEE 1 .i. �Cj� ❑ Surcharge FEE El Other FEE INSPECTOR# PERMITVALID �//C��J- V�2-2 t0 -7 -2- :2) 11 Food Hand/ler ❑ Check# IkV AMOUNT PAID K �� Date TF 2-o 2, INVOICE# b ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 'Lp Z Y 48-02-034 y, j-2- MASTERFILE RECORD INFORMATION PINK