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SAN JOA�,UIN COUNTY ENWRONMENTAL HEALTH DEPAR NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Program at Existing vvF((��a,cility ❑New EH Program and New Facility <br /> Facility ID FA 000S'9_90 Program Record ID Pz 2`- E -;2-77 <br /> Facility Address (QUI �� wJ1 <br /> - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 11 No El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit -Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility------------------El Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use CSTA and B forms <br /> HOUSING PROGRAM(2400) <br /> 11 hotel/�1otel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee(lousing(2700) Use Employee flousine/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 11W Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number oPools/Spas at Facility ElPool 11Spa 11 Out of Service Pool/Spa El Natural Bathing.Area <br /> f <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm -------Maximum number of birds [1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical"Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill El Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste"fire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ DumpSterS>20 cu yd----Numbcr of Units___ ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(400) <br /> El Primary Care El Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 11 Transfer Station El Veterinary Clinic F-1CommonStorage Facility----El 2- 10------- El I t -60-- - ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P;VS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON f Day Ph Night Ph <br /> M � <br /> PROGRAM ELE <br /> ENT 1-7Yo FEE ❑ Surcharge FEE ❑ Other FEF: <br /> INSIIEC-1.011# 00(0 0 PERMIT VALID to ❑ Food Handler <br /> ❑ Check a ANIOUNT PAID Date p INVOICE 9 <br /> ❑ Cash RE•VIEWE•D13)' iQ ACCOUNTING OFFICE Date to O'�— <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />