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L7 <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATIONFORM <br />E3New EH Program at Existina Facilitv - amaw FH Pi onrnm and New Facility <br />Facility ID nCD;1-71-57Le Pro ram Record ID K0,5y-X04kJ <br />Facility Address !31 X N. � 0 MI SS- . IjnC .fib <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 <br />Vehicle # <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 ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make_-_ <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from <br />to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />O Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP 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 AST$ <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR 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 Hoasina/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW 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 of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200). <br />❑ Pumper Vehicle Registration # License # Capacity <br />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 <br />❑ Sludge/Ash Sit <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility <br />❑ CIA Landfill S' <br />❑ Refuse Vehicles (9 of Units) 11Dumpsters > 20 cu yd (*of Units) <br />ElFarm/Ranch left, <br />MEDICAL WASTE PROGRAM (4500) <br />O�j <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ ,Ie?d aU%B <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 <br />❑ 11-60 ❑>tiators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br />NQ4;T,-.t4, <br />��r+�l•,� <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 7/ Day Ph Z047 -4/Z3-4 eght.P4 %-&(-�G`r+'"�►T <br />PROGRAM ELEM NTFEE L ❑ Surchar F E ❑Other FEE _ <br />INSPECTOR# PERMIT VALID 22 t0 2 ❑ Food Handier <br />—_ <br />❑heck# AMOUNTPAID 2 ,� Date l0 -Ahl22 INVOICE# V <br />OOOJIIIJJJ h REVIEWED BY ACCOUNTING OFFICE Date Z <br />48- -034 MASTERFILE RE ORD FOr <br />�01/23113�5h��� e�sc ng <br />