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LSANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT II MASTERFILE RECORD INFORMATION FORM ew EH Program at Existing Facility ❑New EH Program and New Facility M7 o Facility ID 361 Program Record ID P-05+781q ® Facility Address 1-1 1 S i4i Orr StkL&& G/e2Zd(P (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market--Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event—Dates of operation from to ❑ CFO ❑ A ❑ B ' DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)-------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233, 2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution--Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) PAYMENT Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa -R-FE3-ep' ing Area VECTOR CONTROL PROGRAM(4000) �,7. ❑ Poultry Farm-------Maximum number of birds Af%KfnVeR022 TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) oo��11jj�f,, ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facc tm"V� ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-TenygW �ellfty(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTEpROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form I/ C EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM s CONTACT PERSON '0- 1 Z Day Ph ZV 1,0q Night Ph PROGRAM ELE NT FEE ElSurcha/rge F 11 ElOther FEE INSPECTOR# PERMIT VALID It/ 1C ZZ tO (Z( 3 ( ZZ ❑ Food Handler ❑ heck# AM UNT PAID Date (I 2,V 2- 2--INVOICE# .36 a SS Cash REVIEWED BY ACCOUNTING OFFICE Date S/ 22-- 48-0 -034 MASTERFILE RECORM INFORMATION PINK 1/23113