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SAN JOAQUlN COLD 'Y IV M MENTAL HEALTH 0, X `u Er <br /> MASTERFILE RECORD [INFORRMT[ION FORM <br /> ❑ C <br /> New EH Program at Existing Facility p. lew EH Program and New FacilityQ13 <br /> Program Record ID <br /> Facility Address Ailtt <br /> (Please check the appropriate description and specify—size, number of units and 2jLtineni_information.) <br /> FOOD PROGRAM(1600) ,�ired. YES El NO 13 <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course r2g.! <br /> • Commissary 0 Dry storage only El with Food Preparation OVending Machines Number of Units <br /> 0 with Meat Market only 171 Multiple DepartmentsO Prepackaged Goods Only <br /> • Retail Market----Square footage _ i <br /> • Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 0 Mobile Food Prop Unit ' Make Vehicle Type Color <br /> Registration License Sticker# ❑ Ice Plant <br /> El Temporary Food Facility--Dates of operation from to Produce Stand <br /> El Special Event Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> 0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA D State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) d Per Year _ 0 Recycle/EXemPt System (2299) <br /> ❑ Hazardous Waste Generator-----------Tons Generate <br /> ❑ CRT Off-site Handlers(2218) ------------0 Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility-------------------0 Conditionally Authorized(CA) 0 Conditionally Exempt(CE) <br /> 11 Permit-By-Rule Fixed Unit 0 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 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 h1ousinal–labor Carsitro AorolicafionFonn <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 0 Environmental Assessment D UST-CAP Site 0 Local HW Cleanup Site El NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site El non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600)0 Pool ❑F1 Spa Out of Service Pool/Spa F1 Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) Kennel <br /> 0 Poultry Farm-------Maximum number of birds <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC_PROGRAM(4100) Permanent Cosmetics(4122) <br /> 0 Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> • Pumper Vehicle Registration# License# <br /> • Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) El Ag/Cannery Waste Site 0 Sludge/Ash Site <br /> 11 Landfill 171 Transfer Station 0 Process/Recycle Facility n CIA Landfill Site <br /> ffil-Waste Tire Facility 0 Compost Facility 0 Farm/Ranch Cleanup Site <br /> 1:1 Refuse Vehicles(#or Units) El Dumpsters>20 cu yd (#of Units) <br /> MEDICAL WASTE_PROGRAM(4500) 0 Large Generator 0 Small Generator F1 Limited Hauler <br /> 0 Primary Care 0 Acute Care 0 Skilled Nursing <br /> 11 Transfer Station 11 Veterinary Clinic [I Common Storage Facility 0 2-10 011 -60 1-1 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue 622 cation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR_PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 7-'i/L2,_ FEE_� 0 Surcharge FEE_ 171 Other FEE <br /> "I Ir <br /> 0 Food Handler— <br /> Ns <br /> INs7PECTOR# <br /> PERMIT VALID to <br /> C 4 <br /> Date INVOICE <br /> Check AMOUNT PAID <br /> ---I / Date <br /> ACCOUNTING OFFICE <br /> 0 Cash REVIEWED BY <br /> MASTERFILE RECORD INFORMATION PINK <br /> 48-02-034 <br /> 11/15/07 <br />