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<br />SAN JOAQUIN COUNTY END )NMENTAL HEALTH DEPARTM. <br />MASTERFILE RECORD INFORMATION FORM <br /> <br /> <br />New EH Program at Existing Facility <br /> <br />ew EH Program and New Facility <br /> <br />Facility ID <br /> <br />Program Record ID kos-4-1-2-1-717 <br /> <br />Facility Address j7 <br />(Please check the appropriate description and specify size, size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only <br />0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Cl Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) <br />Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 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 />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />0 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station O Ag/Cannery Waste Site <br />Waste Tire Facility CI Compost Facility O Process/Recycle Facility <br />Refuse Vehicles (# of Units) <br /> <br />El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON (2.7Z L., et le <br />PROGRAM ELEMENT <br />iNSPECTOR # <br />Check # <br />.>fCash REVIEWED BY — ACCOUNTING OFFICE Date / <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />9 s-cD- <br />Vehicle Type Color <br />License # 76043 7 L- I Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0 A B <br />0 Program 3 Facility <br />El PBR (2231) 0 PBR HHW (2236) <br />Number of Pools/Spas at Facility 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />License # <br />0 Package Treatment Plant 0 Chemical Toilets ----NuRttisylinits <br />pkt.1 5 Esvig01011 .4.ENTKIA51,4-r <br />viEALThDEPPU 'STudge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Boagi <br />CI Bailee <br />Capacity DEC 1 IS 2°9 <br />ingle Use (4120) <br />nt Mobile Facility (4131) <br />Vehicle # <br />kpight Ph <br /> FE Li Other FEE El Surchal•ge <br />PERMIT VALID to 0 Food Handler <br />AMOUNT PAID Date INVOICE # 303 <br />ERGENCY NO-177ICEON(FfR THIS FACILITY 0/OR PROGRAM <br />t,' (7--bay <br />0 LS-6 <br />1/23/13