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SAt`1 JOAQUIN COUNTY ENVIRONMENTAL:HEALTH DIVISION <br /> MASTERFII E RECORD INFORMATION FO I(EH 00 69) <br /> at Existiu>;Facility <br /> New EH Pro and New Facility <br /> ❑New EH Pro <br /> Facility ID C I�' 4 Program Record TD C <br /> Facility Address 3loa� S cis` w� PO <br /> (Please Check the appropriate description and specify size•number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> - S Footage _Food Handlers Course required: YES❑ No 11Restaurant: Searing Capacity - Square g ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation <br /> ❑ Retail Market—Square footage ❑ with Meat Market only C1 Multiple Departments 13 Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle—Make License X Sticker# <br /> Registration Color <br /> 13 Mobile Food Prep Unit—Make Vehicle Type <br /> License# Sticker# <br /> Registration# 13 Ice Plant <br /> C3Temporary Food Facility--Dates of operationfromtrom ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> to <br /> DAIRY PROGRAM (2000) <br /> C3- Grade B Dairy ❑ Milk Dispenser (umber of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> CUPA C3 State Facility Surcharge(2399) - <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> ❑ Hazardous Waste Generator-2222-- — - — Conditionally Exempt(CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Condit❑ permit-By-Rule <br /> Rule Household Hazardous Waste <br /> ❑Permit-By-Rule Fixed Unit y <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and-B-LO—r-s - <br /> HOUSING PROGRAM(2400) <br /> El Jail or Exempt Institution—Number of Units <br /> 11 HoteVylotel------Number of Units <br /> Employee Housing(2700) Use Lm-plplee Ho ri ^/L.A Como Aavlicarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site [3non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity. Vehicle# <br /> [3 Pumper vehicle-Registration# License# - <br /> ❑ PackageTreatmentPlaut ❑ Chemical Toilets—Number of Units <br /> ❑ Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> El Landfill C3 Transfer Station ❑ Ag/Cannery Waste Site EI CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>10 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) - <br /> ❑ Primary Care 13 Acute Care ❑ Skilled Nursing Cl Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑>60 generators <br /> 13 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —13 22- 10—❑ l l -60-- g <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY I'IOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph�— Night Ph <br /> CONTACTPERSON s <br /> �� FEE—� ❑Surcharge Fee ❑ Other FEE — <br /> PROGRAM ELEMENT (�- - - ❑ Food Handler <br /> INSPECTOR# S<�a PERMIT VALID�— to INVOICE#— <br /> AINIC IIM PAID Date / <br /> ❑ check# Date S j <br /> AccouNr¢tG OFFICE c <br /> ❑ Cash REVIEwEDar Rev.otro,vv <br />