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MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facift ❑New EH E222M and New Facility <br /> Facility IDQ'L Pro ram Record ID <br /> Facility Address_�A`I5 W- i?,� L r'r _ <br /> (Please check the appropriate description and specify size.number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No ❑ <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 /> 0 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 /> IJ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CE1PA ❑State Facility Surcharge(2399) <br /> HADOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) -❑Silver Only(22222) ©Appliance Recyclers(2217) <br /> Tiered Permitting Facility. ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> s ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and Q forms <br /> HOUSING PROGRAM(2400) <br /> © Hotel/Motel-----Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Houslnv/L abor Camp App//cation Form <br /> SITE MITIGATION(2900) tU CIERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ Uic Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site © RWQCB Cleanup Site ❑Water Quality Remedlation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolslSpas at Facility 13 Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm------Maximum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> §OLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility Cl Compost Facility ❑ Process/Recycle Facility 0 CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) © Dumpsters n 20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site <br /> ME=DICAL WA M E!R2GRAM(4500) <br /> 0 Primary Care 0 Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 48.02.003 Slue App/lkatlert Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph might Ph <br /> PROGRAM ELEMENT 2-220 FEE '7-1-3—d D ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR PERMIT VALID to ❑Food Handier <br /> r) ❑ Check 0 AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED ay ACCOUNTING OFFICE Date <br /> C, 3�u-_ 9E:6,>.tl)I.n i�l,� 2oOQj <br /> 4"2-034 MASTERFILE RECORD INFORMATION PINK <br /> 11115/07 <br /> i <br />