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SAN JOAQUIN COUNTY ENAI MENTAL HEALTH DEPARTW MASTERFILE RECORD INFORMATION FORM E EH Program at Existing,Facility ❑New EH Pro ram and New Facility ID (A'C'C' 4s7Pro ram Record IDS (l 3 Facility Address L[UC U_�_, �IcdI � (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units C1Retail Market-- Square footage ❑ with Meat Market only ❑ Multiple Departments 13 Prepackaged Goods Only El Mobile Food Vehicle-----Make ` Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit -`flake Vehicle Type Color Registration# License# Sticker# El Temporary Food Facility-----Dates of operation from to 11 Ice Plant El Special Event --Dates of operation from to Produce Stand DAIRY PROGRAM (2000) El Grade A Dairy El Grade B Dairy El Milk Dispenser --Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility------------------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number oCAST UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM(2400) ❑ C3 Hotel/Motel-------Number of Units Jail or Exempt Institution-------Number of Units Emplo%ce(lousing(2700) Use Employee Housing,/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) El Environmental Assessment ❑ UST-CAP Site F-1LocalHW Cleanup Site ❑ NPL/SEP Cleanup Site 11 UIC Site ❑ Abandoned IINN'Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pool�'Spas at Faciliq ❑ Pool El Spa 11 Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm -------:~Maximum number of birds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 1:1 Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) 11 Pumper Vehicle-Registration# License# Capacity Vehicle# 1:1Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Process/Ree cle Facility ❑ CIA Landfill Site ��1'astc"I'irc Facility [I Compost Facility Y y ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units_ ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care ❑ Skilled Nursing El Large Generator ❑ Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02- 10- 10------- ❑ 1l -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PI,VS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELENIENf `► T ( FEE ❑ Surcharge FEE ❑ Other FEE INSPECroli# C C' PERM("f VALID to ❑ Food Handler ❑ Cl,cck k ANIOUNT PAID Date INVOICE# ❑ Cash REVIEWED 4Y a( ACCOUNTING OFFICE 4L Date (Y O Masterfile Record Pink 48-02-034 10/6/2003