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"SAN JOAQUIN COUNTY EN NMENTAL HEALTH DEPARTIv T <br /> MASTERFILE RECORD INFORMATION FORM <br /> New ElPro ram at Existin Facility ❑New EH Pro ram and M­.Facilit <br /> Facilit ID FA to14a*(0 Program Record ID <br /> Facility Address 3.51(0 NeWto n 90( <br /> - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El 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 /> 13 Temporary Food Facility-----Dates of operation from to El Ice Plant <br /> ❑ Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM (2000) <br /> 1:1 Grade A Dairy 11 Grade B Dairy 13 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) ❑ Silver Only (2222) ❑ Appliance Recyclers (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 /> ❑ <br /> 11 Hotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units <br /> Employee Housing(2700) Use Employee Housing/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 HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 Pool ❑ Spa ❑ Out of Service Pool/Spa 1:1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm -------Maximum number of birds [3 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(412 1) E3 Body Piercing(4120) Cl Permanent 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 /> 13 CIA Landfill Site <br /> ,6 Waste Tire Facility [jCompost Facility ElProcess/Recycle Facility <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> iler <br /> El Primary Care E3 Acute Care 11 Skilled Nursing ❑ Large Generator ❑ Small Generator E3 Limited ra ors <br /> El Transfer Station C3 Veterinary Clinic El Common Storage Facility----Cl 2- 10------- 13 1 1 -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 /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT H FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# OGG O PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID F Date INVOICE# L' _ <br /> ❑ Cash REVIEW FD BY �I Q (3 q,J ACCOUNTING OFFICE Date T t SQ� <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />