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SAN JOA <br /> QUIN COUNTY E ONMENTAL HEALTg DEPART NT S)000 6&o g <br /> MASTERFILE RECORD INFORMATION FORM L,)O l <br /> ❑New EH Pro at Existin Facility .! <br /> Facilit ID ❑New EH Pro and NewFaciii F4` ry <br /> Pro ram Record H) <br /> Facility Address Z <br /> (Please Check Ule appropriate description and specify • <br /> —OD PROGRAM(1600) size �num�b�e�r of uGni <br /> ts andp_ertine�ntn orm ) <br /> t <br /> ❑Restaurant: Seating Capacity Square Footage <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparationp Food Handlers Course re aired: <br /> ❑Retail Market---_Square footage ❑Vending Machines- YES❑ No ❑ <br /> ❑Mobile Food Vehicle---M ke �-- ❑nth Meat Market onlyNumber of Units �_ <br /> ❑Multiple Departments ❑Prepackaged Goods Only <br /> Registration# Vehicle Type <br /> ❑Mobile Food Prep Unit-Make License# Color <br /> Registration# Vehicle Type Sticker# <br /> ❑ Temporary Food FacilityLicense# Color-- <br /> Special Event -_ —Dates of operation from Sticker# <br /> Dates Of operation from to — <br /> DAIRY_ PR (2000) to ❑Ice Plant <br /> ❑ Grade A Dairy ❑Produce Stand <br /> ❑Grade B Dairy <br /> CEPA Cl State.Facility ❑Milk Dispenser—Number of Containers in <br /> HAZARDOUS WASTE <br /> Surcharge AM( Multi-Head Unit <br /> ASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator--_ __ <br /> ❑CRT Offsite Handlers 2218 Tons Generated Per 2) ❑Recycle/Exempt System(2299) <br /> ( ) El Silver Only(2222) <br /> Tiered Permitting Facility__ __ __ El Conditionally Authorized CA I ❑Appliance Recyclers(2217) <br /> ❑pmt B ( ) ❑ Conditionally Exempt(CE) <br /> ❑ABOVEGROUND STORAGE TANK FACILITY Y Y Rule Fixed Unit ❑Pmt-BY-Rule Household Hazardous Waste <br /> 2390) <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use m er nail B ops <br /> NOUSIN—OGRAM(2400) <br /> ❑HOtel/MOtei----Number of Units — <br /> Employee Housing(2700)Use Entnlovee Housipe/Labor Camp 4 /kation 11 Housing or Exempt Institution <br /> -!'TE MI_ TIGAT�ON(2900) Number of Units <br /> UNDERGROUND <br /> ElEnvironmental Assessment ❑ UST-CAP Site ❑Local CleaCTIuE S{ON CONTROL(3000) <br /> ❑Abandoned HW Site ❑non-NPL✓SEP Cleanup Site ❑RWQCB Cleanup Site <br /> Site PEEP CleeaanupSi e ❑UIC Site <br /> RECREATIONAL HEALTH PROGRAM(3600) Qttysite <br /> Number Of POols/Spas at Facility [j pool <br /> VECTOR CONTROL PROGRAM(4000) ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> ❑Poultry Farm--Maximum number of birds c < <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) S J2 009 ❑ Kennel <br /> ❑Tattooing(412 1) ❑Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) ❑Permanent Cosmetics(4122) <br /> ❑ Pumper Vehicle—Registration# License# <br /> ❑ Pumper Yard Capacity. Vehicle# <br /> ❑Package Treatment Plant 11 --- <br /> Chemical Toilets <br /> SOLID WASTE PROGRAM(4400) Number of Units <br /> ❑Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site <br /> ❑Waste Tire Facility ❑ Compost Facility13Sludge/Ask Site <br /> El Refuse Refuse Vehicles— ❑ PrOcess/Recycle Facility 11 CIA Landfill Site <br /> Units ❑Dumpsters>20 to yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Farm/Ranch Cleanup Site <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 11 Transfer Station 11 Veterinary ❑ Common storage Facility—[]2_ 10_—❑ 11-60-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePfVSEHD46-02-003Blue Application Form >❑ 60 generators <br /> CONTACT PERSON EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> PROGRAM ELEMENT X965 FEE El <br /> Ph Night Ph <br /> INSPECTOR# (,Q„q�/71 --� ElSurcharge FEE 1:1 Other FEE <br /> --r-n` PERMIT VALID to 13 Food handler <br /> ❑ <br /> 11 Check# AMOUNT PAID <br /> �_Cash ate <br /> REVIEWED BY DINVOICE# <br /> ACCOUNTING OFFICE r x- <br /> 48-02-034 Date <br /> 1 6161 Masterfile Record Pink <br />