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BAN JOAQUIN COUNTY E RONMENTAL HEALTH QEPARTVI MASTERF CORD INFORMATION FORM w EH Program at Existing Facility ❑New EH Program and New Facility Facility ID a 60;?,3 0 Program Record ID Tosc 36D Facility Address �Z a N v } �%��- UO G� Z G k� �l �-Z 44 0 (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 ❑ 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 ❑ CFO ❑ A ❑ 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 ❑ 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 Remedlation 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 ❑ fennel 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 ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units _ SOLID WASTE PROGRAM(4400),� ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/As /�/�� 171 Waste Tire Facility El Compost Facility 11Process/Recycle Facility El CIA Lan*PS. e9 El Refuse Vehicles(#or Units) 1:1Dumpsters>20 cu yd (#of units) ElFa*WZlnnch egite MEDICAL WASTE PROGRAM (4500) h Eryy�Ui, ❑ Primary Care 11 Acute Care 11 Skilled Nursing El Large Generator El Small Generator' s Ty CO❑ Transfer Station E3 Veterinary Clinic El Common Storage Facility ❑ 2- 10 El 11 -60 11 >60� PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM _ CONTACT PERSONGJGlJ f3tv1 Day Ph GI I(O e }1 I •15ti1Slight Ph PROGRAM ELEMENT-4).117) FEE_f ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID t0 13 ❑ Food Handler ❑ Check# (SGl AMOUNT PAID Date 221, INVOICE# oZ"f 3 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ALL 48-02-034 ' O L - MASTERFILE RECO D INFORMATION PINK 1/23113 J4