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r <br />-1 dank -1 <br />[ t <br />SAN JOAQUIN COUNTY ENV?WW MENTAL HEALTH DEPART . . <br />MASTERFILE RECORD INFORMATION FORM <br />liNew EI -1 Pro ram at Existing Facility _./4 (' C.) ( ( ❑New EH Pro ram and New Facility <br />Facilit IDLI t �f , I <br />Program Record ID Q a <br />Facility Address .3'34J A)Q vy 54A <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 Ilantllers Course required: l'Ics ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Numbcr of Units <br />❑ Retail Market ---- Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make Vchicle 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 <br />❑ Special Event -- Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Ice Plant <br />❑ Produce Stand <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 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 USTA and B forms <br />ROUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution -------Number of Units <br />t;mployee Ilousing (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 ❑ Pool <br />VIXTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds _ <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />El Tattooing (412 1) ❑ Body Piercing (4120) El 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 />El Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑Sludge/Ash Site <br />13 Waste Tire 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 (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- ❑ 2 - 10 ------- ❑ 1 1 - 60 ------ ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 BlueAppliealion Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />PROGRAM ELEMENT (, l o FEE _ <br />INSPECTOR # W0 b PERMIT VALID <br />❑ Check # AMOUNT PAID <br />❑ Ca:,h REVIEWEDBY -3jQ_ C/N <br />❑ Surcharge FEF. <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date S16�DS <br />r <br />Masterfile Record Pink <br />48-02-034 <br />I n 4,1, MM <br />