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LSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART112L+'NT <br /> MASTERI4LE RECORD INFORMATION FORM <br /> ❑New EFI Program at Existing Facility Wew Eli Program and New Facility <br /> Facilit ,H) I Program Record ID <br /> Facility Address �s IA/1&7p^ <br /> (Please Check the appropriate description and specify EiLe,number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Stating Capacity Square Footage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vendiug Machines—Number of Units <br /> ❑ Retail Market—Square footage _ ❑with Mmt Markct 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 It Stick"If - <br /> ❑Temporary Food Facility--.Dates of operation from - to ❑ lee Plant _ <br /> ❑ SpeciatEvent -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) 1 <br /> ❑ Hazardous Waste Generator--Tons Generated Per Year ❑Recycle/Exempt System(2299) _ <br /> ❑CRT Offsite Handlers(221&) ❑ Silver Only(2222) _ [I Appliance.Recyc]ers(2117) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemrit-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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> 0 HoteUlHotel--Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employ"Housing(2700)Use F,mple1w Hotrsinzlfabor Camp Application Farts <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local BW Cleanup Site. ❑NPUSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑Spa ❑Out orser ice 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) El Pod),Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> �G t tgj Pumper vehicie—Registrationht,114L, License# _ .Capacity Z_5''- < Vehicle# <br /> ❑Pumper Yard Ef Package Treatment Plant- ❑Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station': ❑ Ag ICannery Waste Site ❑ Sludge/Ash Site _.., <br /> ❑Waste Tire Facility ❑ Compost Facility _ ❑ Process/Recycle Facility ❑ CIA-Landfll Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpstcrs>.20 cu yd--Numixr of Units _ ❑I'arm/Rauch Cleanup Sit <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care Cl Acute Care 13 SHHed Nursing ❑Large Generator ❑ Small Generator ❑Limited hauler <br /> ❑ Transfer Station ❑ Wier inary Clinic ❑ Common Siorage Facility.._--El z- to----❑ I1-oU- -f7>GO gcneracars <br /> PU6_L_EC_=V4ATFR SYSTEM PROGRAM(4600%Use Pi SSAD46-02-003 Blue Ap�(icaYinii T%man <br /> EMERGUICY NOTIMATlOtr FOR I10 FACILITY.ANDIOR PROGRAM <br /> Sur <br /> f ONTA.0 Il PERSON RSON_.-L3rYkY—Z/-%/.�'Z�tdL�-�Prt�d-- .._ - tav l i �� Ni�lil s <br /> Y' 1 :ri.i2Aer EL1:hIEti1 TUE_ j - 0r�rargol t€ '. ❑ Other l Er': <br /> L,is i.cr0ict(. 5 �4�5�- ITIL1,11) VALIJ - - to --- 17 hood Nandi r <br /> -- <br /> 171 .`iu b::;` AMOUNT PAII) <br /> 3Y .Aft Vin 11N�'01PICL 'JJatc <br /> z. ,f3 ,i l:rt;•_ <br />