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SAUJOAQUIN COUNTY l,,..,,,1R0NMENTAL HEALTH DEPAR'; tNT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Exii isting Facilit ❑New EH Program and New Facility litID 71Y Program Record ID le Facility Address _-7l Z- 3 - D Z-/ilL' AU4- (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 ❑ 11Commissary 13Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market---Square footage ❑ with Meat Market Only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -Wake Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# 1:3 Temporary Food Facility--Dates of operation from to 11 Ice Plant 1:1 Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit i COPA ❑ State Facility$urcharge(2399) HAZARDOUS WASTE�PROGRAM(2200) ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Ha'ndiers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2297) Tiered Permittin ��Facilit ------ ❑ Conditionally Authorized CA ❑ Conditionally Exempt CE ❑ Permit-lay-Rule Fixed Unit ❑ Permit-13Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Ilse UST A and B form HOUSING PROGRAM (2400) ❑ Hotel/Motel----Number of Units 11 Jail or Exempt Institutiober of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) �I UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at �acility El Pool 11 Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farmmumnumber of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) 1 ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# 11Pumper Yard 11Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ AgiCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAlM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12- 10 ❑ 11 -60 ❑ a 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 11 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1I Day Ph Night Ph PROGRAM ELEMENT Z!h1440 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#r- PERMIT VALID to ❑ Food Handler ❑ Check# V AMOUNT PAID Date INVOICE# _ IJ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07