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SAN.JOAQUIN COUNTY L11TV170NMENTAL HEALTH DEPA �T <br /> MASTERFILE RECORD INFORMATION FORM <br /> Nexv EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilitv ID U Q Io 5-0-7 Pro ram Record ID S� <br /> Facility Address •- IM0 E, P,0-41 Jt <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 ❑ 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 Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <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.PROGRANT(2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsjte Handlers (2218) ❑ 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ hotel/,Nlotel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee Ilousing(2700) Use Employee flousina/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IINN Site ❑ non-NPL/SEP Cleanup Site ❑ Rw'QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/`)pas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farm -------ylaximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <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 /> El Landfill El Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> w Waste"fire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units __ ❑ Dumpsters>20 cu yd----Number of Units _ ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(400) <br /> 1:1 Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator El <br /> Hauler <br /> El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10------- El 11 -60- ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PfVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Ni ht Ph <br /> PROGRAM Ei,i mENT 0 Iflq 0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSI'ECroli# corno PERMIT VALID to ❑ Food Handler <br /> ❑ Check k ANIOLINT PAID Date INVOICE# <br /> ❑ Cash RiiviENVED nl'j'� I O (p ACCOUNTING OFFICE Date <br /> Masterfile Record Pink <br /> 48-02-014 <br /> Io6-1ou3 <br />