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Et <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH <br />Facility Address Yjti2 Weil( C.c�' ,ik- /30 <br />, S'ydAiy,,, ' g910, <br />(Please check the appropriate description and specify snumber of units and pertinent information.) <br />ize, <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />Food Handlers Course required: YES ❑ NO ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />Retail Market --Square footage /180 ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) -------- —>-Tons Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PER (2231) ❑ PER HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel --Number of Units ❑ 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 ❑ 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ppAAVV CC <br />C1 Body Art Practitioner Reg (4110) C1 Mechanical DSPS Notification (4115) 1:1 Body Art Facility-Singi8�9e ENT <br />❑ Body Art Facility -Sterilization (4121) ❑ Body ArtTemp Event Co-ord (4130) ❑ Body Art -Temp Even ff&131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity '%R,O9 2W <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) SAN JCAQUIN C OUW <br />NTAL <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ RONM WIME <br />�9�1�11@rMENT <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd I# 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 112 - 10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />(/ �7 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON: - c� '2 7) `t'T Day Ph.. , W- q42 7 Night Ph <br />PROGRAM ELEMENT I V% FEE T L 15 — ❑ Surcharge FE ❑ Other FEE <br />INSPECTOR # 2 PERMIT VALID q Z Z t0 3 '� ❑ FOOd H der <br />❑ Check # i AM NT PAID z % Date 9 Z 2 I VOICE # ctvTr <br />❑ Cash REVIEW EO BV ACCOUNTING OFFICE Date <br />/23113 <br />4 4 MASTERFIL ECOR INFORMATION PINK <br />n3 t3 ©K ,/, f o reemi 1 <br />