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ESAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE <br /> PAR NT <br /> MASTERFILE RECORD I�(FORtviATION FORM <br /> New EH Program at Existin Facility <br /> ❑New EH Pro am and New Facility <br /> Facility ID �Q Z Sv( Program Refcord TD 5a 7 <br /> Facility Address I D S S <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: —Yes ❑ NO ❑ - <br /> ❑ Restaurant: Seating Capacity Square Footage <br /> [I Commissary ❑ Dry storage only <br /> [3 with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑with Meat Market only [I Multiple Departments ❑oPrepackaged Goods Only <br /> Vehicle Type ColSticker# <br /> [3Mobile Food Vehicle-----Make License <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from ❑to Produce Stand <br /> ElSpecial Event --Dates of operation from <br /> DAIRY PROGRAM(2000) ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year 11 Recycle/Exempt System(2299) <br /> ElHazardous Waste Generator------------ 22 ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers (2218) <br /> [I Silver Only(2___) ❑ ditionally Exempt(CE) <br /> Tiered PermittingFacility------------ ❑ Conditionally Authorized(CA) <br /> y— — — ❑ Permit-By-Rule Fired U4;p� <br /> By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) NumbeUNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use DST <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution------Number of Units <br /> ❑ Hotel/i✓Iotel-------Number of Units <br /> Employee housing(2700) Use Employee Housin/Labor Camp Application Form <br /> SITE MITIGATION(0) Use <br /> UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> te Cleanup Si <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNA R„QCB Cleanup ite ❑Site PL/S❑ Water Quality Remediation n Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) 11 Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> ElPool ❑ Spa C] Out of Service PooUSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm-----Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT C❑O Boa TP ePRO rcing(ARAM (4100) [1 Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) <br /> LIQUID WASTE PROGRAM(4200) License Capacity 120) Vehicle# <br /> # <br /> ❑ Pumper Vehicle--Registration# ❑ Package Treatment Plant ❑ Chem ical Toilets-------Number of Units <br /> ❑ Pumper Yard <br /> PROGRAM(4400) ❑ Sludge/Ash Site <br /> SOLID WASTE <br /> El Transfer Station El Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Landfill C3 Process/Recycle Facility <br /> [I Waste Tire Facility ❑ Compost Facility ❑ Dumpsters>20 cu yd----Number of Units <br /> ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Skilled Nursing ❑ Large Generator [3 Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑ >60 generators <br /> ty----- �- 10-------❑ 11 -60------ <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility ❑ <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PNS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Ph <br /> Day Ph Night <br /> CONTACT PERSON ❑ Other FEE <br /> FEE ❑ Surcharge FEE _ <br /> rPROGRANI ELEMENT 3 to ❑ Food Handler <br /> OR# PERMIT VALID INVOICE# <br /> AINIOUNT PAID Date <br /> # Date <br /> ACCOLJhTING OFFICE <br /> REVIEWED BY <br /> ❑ Cash Masterfile Record Pink <br /> 4M2-034 <br />