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SMN JOAQUIN COUNTY ENONMENTAL HEALTH DIVISIO16 MASTERFILE RECOKD FORMATION FORM (kH 00 69) ❑ New EI-1 Pro rain at Exi-sting Facility ❑New El-1 Program and New Facility Facility ID �(�� `'� p Pro ram Record ID R-C Facility Address 1 ;� l �� '�'(' %'��Y`�.\ Na. U (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) FNV�R � �ICr�VICES ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: VEs❑ 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 Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ 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 COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 13�Hazardous Waste Generator----------Tons Generated Per Year cJ_�� ❑ Recycle/Exempt System Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms 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 IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation 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 ❑ Kennel TATTOO, BODY PIERCING, PERMANENT 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-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blne Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON A�\Y\(,; DayPh_, ,'P 'I Night Ph C`t� PROGRAM ELEMENT 22Z ] FEE !S 6 0(7 El Surcharge FEE ❑ Other FEE INSPECTOR# 3M o i,�V PERMIT VALID (��j 03 to 11431 1 63 , /_❑ Food Handler / 11 Check# AMOUNT PAID LL- Date 63 �yANVO(CC# 01 D b3 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Y,11KDate ie W O_AA&-Z� p _272� EI 10069 Pink Form Rev.02/25/03