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rSAN JOAQIJIN COUNTY EN V 1RONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br />rF—acility ID Program Record ID <br />Facility Address <br />Registration # <br />Mobile Food Prep Unit--Make <br /> <br />Registration # <br />to <br />to <br />Tons Generated Per Year 0 Recycle / Exempt System (2299) <br />Silver Only (2222) 0 Appliance Recyclers (2217) <br />Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 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 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local IIW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned NW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site Water Quality- emetliatiourBite <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm— Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Tattooing (4121) 0 Body Piercing (4120) <br /> 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle—Registration It License It Capacity Vehicle It <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag / Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles --Number of Units 0 Dumpsters > 20 cu yd ----Number of Units 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EFID 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT 2-Ci (:) -S.— FEE 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # /agOri D PERMIT VALID to 0 Food Handler <br />Check It AMOUNT PAID Date INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE l‘ Date <br />48-02-034 <br />10/6/2003 <br />/o/ /8/017L Masterfile Record Pink <br />(Please Check the appropriate description and specify size, num r of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market ----Square footage 0 with Meat Market only <br />Mobile Food Vehicle -----Make <br />:Wending Machines —Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />ONew EH Program and New Facility <br />Food Handlers Course required: YES 0 No 0 <br />— <br />.51)0oo /14036o <br /> K.0 <br />jez-01C0 <br />ftM <br />Oa a ( <br />Temporary Food Facility Dates of operation from <br />Special Event --Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> <br />0 Hazardous Waste Generator <br />0 CRT Offsite Handlers (2218) <br />Tiered Permitting Facility <br />0 Milk Dispenser---Number of Containers in Multi-Head Unit <br />0 Ice Plant <br />0 Produce Stand <br />0 Limited Hauler <br />0 > 60 generators