Laserfiche WebLink
SAN JOAQUIN COUI,�i ::, _VIR0 MENTAL HEALTH DEPARTMENT <br /> MASTF;:I i_CORD INFORMATION FORM _ <br /> ❑ New EH Program c:t Existing F _ _IXNew EH Pro ram and NewFacility <br /> Facilit ID CZ>f _ `Program Record <br /> Facility Address _Z2`-I S L..� . G�� 2T1,=,_(Z_ <br /> (Please check the appropiii;te cia:: nd specify size, number of units anirtinent informatio4, G <br /> FOOD PROGRAM (1600) (� V n. <br /> , -� ��� S. I 1 <br /> ❑ Restaurant: Seating Capcicii. Square Footage Food Handlers Course required: Yes ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage c,,,, .) with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footac ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make__ Vehicle Type Color <br /> Regislralion _ License# Sticker# <br /> ❑ Mobile Food Prep Unit--K:I*Ki. Vehicle Type Color <br /> Rt.gis;rc.tion `r_ _ License# Sticker# <br /> ❑ Temporary Food Facility--D: -ation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event---Date,,,of oprr to [] CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Busine OU) Number of chemicals: <br /> ❑ CaIARP Program ram 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator -----> Tons Generated Per Year <br /> ❑ Tiered Permitting Fa..:iiity- A(2232) ❑ CE(2233, 2234,2235,2237) ❑ P13R(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage'tan:. T) (2800) Number of ASTs <br /> ❑ Underground Storag�Tan'. F . . 3T)(2.300) Use USTA andEl forms <br /> ❑ Other CUPA Promani <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of tin,;: ❑ Jail or Exempt Institution----Number of Units <br /> Employee Housing(2700) Use Em ,!rsinct/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environrnental Asse:,smen� P Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Sitc ! JSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEAL7 H 'I:IGI <br /> Number of Pools/Spa: -!I1 , Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PPOG,?._ ',I( . <br /> ElPoultry Farm-------M.-,•:in.ul I: ❑ Kennel <br /> TATTOO.BODY PIERCING,PERr., .—TIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (41, i 11echanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilizatiul: Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAls_(420U) <br /> I Pumper VehicleR:-g1_,iratio; _ License#3y$b2 r-t Capacifyln)/Z) F g6vVehicle# S <br /> ❑ Pumper Yard ge Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGR_W, (4,UO <br /> ❑ Landfill L] T. _ Al ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ coi . i ity ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (!,,,-f mo::)___ ❑ Dumpsters>20 cu yd(#or Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (45 0, <br /> ❑ Primary Care ❑ Acute C-. Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Vctei ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTE'.1 I ,PWS EHD 46-02-003 Blue Application Fomi <br /> :rY'NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON /W0&1 v" / Day Ph 6,61/3 374/1(c, Night Phjl" / <br /> 2(� iP21�OGRAM ELEI9ENT � 9tL,w ❑ Surchar a FEE 13 Other FEE <br /> INSPECTOR# _ 7 to 1 1:1 Food Handler <br /> 11 Check#_ � Date INVOICE# 7 <br /> ❑ Cash RL', y ACCOUNTING OFFICE Date a <br /> 4802-034 �r '%- //� ! -- v�� MASTERFILER INF RMATION PINK <br />