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,AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID 6l 1-7 � ��` Program Record ID <br />Facility Address 5-0,6-Z k/LS i LA-) S U/ 7-& <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 Food Handlers Course required:. YEs 11No ❑ <br />❑ Commissary 11Dry storage only 11with Food Preparation ❑Pending Machines Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility—Dates of operation from to <br />❑ Special Event —Dates of operation from to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (200) <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) " i <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) ❑ Appliance Reeyclers (2217) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -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 UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Rotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Rousing (2700) Use Employee Housine/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROC.(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPIJSEP Cleanup Site ❑ UTC Site <br />❑ Abandoned HW Site ❑ non-NPIJSEP 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 _ ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />attooing (4121) p!j ' f' ody Piercing (4120)PR 1-73 tl 7c71 �j �ermanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity 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 ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA -Landfill Site <br />❑ Refuse Vehicles Number of Units ❑ Dumpsfers > 20 cu. yd Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator Q Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—[] 2 - 10 ❑ 11- 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Pff'S E11D 46-02-003 Blue Application Form <br />CONTACTPERSON <br />EMERGENCY NOTIFICATION FOR'nits FACILITY AND/OR PROGRAM <br />Day Ph Night Ph <br />PROGRAM ELEMENT FEE <br />INSPECTOR # <br />❑ <br />r't:::•_ :;::'= REVIEW <br />PERMIT VALID <br />AMOUNT PAID <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date r .''` /t l 1 /i' <br />