Laserfiche WebLink
AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilif. ID IZ Program Record ID <br /> Facility Address 5_05Z- k/25-,5 i Lti _2 <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:- Yrs 11No❑ <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 D Milk Dispenser Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) l <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 ❑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 Ilousiag(2700)Use Employee Housine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site• ❑NPL/SEP 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 a�� ©� ❑Kennet <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ) S�I <br /> Iattooing(4121) od Piercing(4120) pJ,ty � <br /> ermanent Cosmetics(4122)�LIQUID <br /> 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•LandrrlI Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Rauch 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--11 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EMD 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 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to 11 Food Handler <br /> __7 <br /> ❑ Check AMOUNT PAID Date INVOICE# <br /> REVIEWED BY ACCOUNTING OFFICE Date <br />