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SAN JOAQU IN COUNTY, MENTAL HEALTH DEPAR' NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ❑New EH Program and New Facility i Facility ID 110-1 Pro ram Record ID P OD Facility Address L✓ T G (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 ❑ ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only Retail Market----Square footage ❑ Mobile Food Vehicle—Make Vehicle Type Color ' Registration# License# Sticker# Vehicle Type Color 13 Mobile Food Prep Unit Make Registration# License# Sticker# 13 Temporary Food Facility--Dates of operation from to Ice Plant ❑ Special Event Dates of operation from to 11 Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) ' HAZARDOUS WASTE PROGRAM 2200 11 Recycle/Exempt S ystem(2299} ❑ Hazardous Waste Generator----------- Tons Generated Per Year ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ e It-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housing/Labor Carno A ofication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ` ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site I RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa C1Out of Service Poo llSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) '} ❑ Poultry Farm-------Maximum number of birds Kennel r TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant [3Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) 1:1 Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site c ❑ 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 t ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue A2alication Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT ~Z. 7 ;�0 - FEE ❑ Surcharge FEE © Other FEE INSPECTOR# 6-13 9��IpERMIT VALlD t0 ❑ Food Handler i ❑ Check# AMOUNT PAID Date INVOICE# 1 I 0 Cash REVIEWED BY ACCOUNTING OFFICE LL Date g os' I ' 1 48-02-034 MASTERFI!_E RECORD INFORMATION PINK 11/15/07