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r • <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New Ell Pro at Existing Facility , BNew EH Pro2m and New Facility <br /> Facilit H) 9'> ®� %, .:�s . ( Pro ram Record H) 5 2Y <br /> Facility Address 6 7 <br /> (Please Check the appropriate description and specify EjK�,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.Machlnes.—Number of Units <br /> ❑ Retail Market---Square footage ❑with Meat Market only ❑Multiple`DegaYtg cuts. ❑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 Dalry ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous NVaste Generator Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑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 /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee HOaSinp/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONT 3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) - <br /> Number of Pools/Spas at Facility ❑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(412 1) ❑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 /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ' ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ®-Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehides.—Number of Units ❑Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 4e 7`1 D FEE 7 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY AccouNTrNc,OFFICE Date 6 <br />