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rr SAR JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMA.TION FORM New EH Prfo� am at xisting Facility ❑New EH Program and New Facility Facilit •ID 'TILL Program Record ID Facility Address ✓ t Y�f'L r (Please Check the appropriate description and specify s___,e number of snits and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant. Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No❑ ❑ Commissary ❑ Dry 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-----Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit--Make Veliicle Type Color Registration# ,-, License# Sticker# ❑Temporary Food Faciliity-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dalry ❑Milk Dispenser---Number of Containers in Multi-Read Unit GUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) i ❑hazardous Waste Generator. Tons Generated Per Year _ ❑Recycle 1 Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit By Rule Fixed Unit t-DyRule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number ofAST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A acrd B HOUSING PROGRAM(2400) ©Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Emnloyee ffousing/Labor Camp Apglication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) .❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPIISEP Cleanup Site ❑UIC Site ❑ Abandoned IIW Site ❑oon-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site RECRI=ATIONAL HEALTH PROGRAM(3600) Number of PoolstSpas at Facility ❑Pool ❑Spa ❑Out of Service Pool/Sp3 ❑Natural Bathing Area VECTOR CONTROL PICOGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMAN15NT COSMETIC PROGRAM(4100) ❑Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑Pumper Vehicle--Registration# License# Capacity Vehicle# ❑Pumper Yard ❑Package Treatment]Plant, ❑ Chemical Toilets Numbcr of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑ Transfer Station ❑Ag i CanneryWaste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA-landfill Site ❑Refuse Vehicles--Number of Units ❑Dumpslers>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator D Small Generator ❑Limited Ranier ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10 ❑ 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVSEHD46-42-003 Blue Agglication Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PICOGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT iffinFEE ❑ Surcharge FEE ❑ Other FEE IrssFECTOR# Z ERMIT VALID , to ❑Food Handler ❑ Check# AMOUNT PAID Date INVOICE# 0 Cash REViEwED SY AccouNnNo OFFICE Date V