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AbAh <br />SAN JOAQUIN COUNTYWV170NMENTAL HEALTH DEPARTI <br />R� <br />MASTERFILE RECORD INFORMATION FORM <br />.New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facilitv ID )0't ," 2 Program Record ID Pv5-50 D -r7 <br />Facility Address E_ . Men ii <br />(Please check the appropriate description and specify si e, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep'Unit Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Vehicle Type <br />License # <br />License # <br />to <br />R <br />_ Color <br />Sticker # <br />Vehicle Type <br />Sticker # <br />Color <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ------------- 1:1 Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility -------------------- El 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 />❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) <br />❑ Environmental Assessment Connecting People with Places P Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site DELTTo CHARTER Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRA <br />Number of Pools/Spas at Facility _ <br />'pa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (401 <br />John MC.E0. <br />El Kennel <br />El Poultry Poultry Farm -------Maximum r <br />' <br />TATTOO, BODY PIERCING, PERMA <br />M: (209) 996-6839 <br />❑ Tattooing (4121) 1 <br />ermanent Cosmetics (4122) <br />l >. Box 5547 <br />LIQUID WASTE PROGRAM (4200) `�tockton, CA 95205 <br />P: (209) 465-1053 <br />F: (209) 465.740 <br />Vehicle # <br />❑ Pumper Vehicle Registration 1i <br />❑ Pumper Yard 'ww.deltacharterbus.com jm.artin(udeltacharterbas•com <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Ag/Cannery Waste Site <br />❑ Sludge/Ash Site <br />Waste Tire Facility ❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of Units) <br />❑ Dumpsters > 20 cu yd (#of units) <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled <br />Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic <br />❑ Common Storage Facility ❑ 2 - 10 <br />❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTArT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # W 0 PERMIT VALID /IJ I to ❑ Food Handler <br />❑ Check# AMOUNT PAID �>�� Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE (",' . Date (Q(-;? �(l] <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />