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-SAN JOAQUIN COUNTY`-`-4I110NMENTAL HEALTH DEPAR` NT MASTERFIL�CORD INFORMATION FORM ' ❑ New EH Pro ram at Existing Facility ONew EH Program and New Facilit Facilit ID �✓r Program Record Facility Address l (Please check the appropriatedescription and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) Food Handlers Course required:. Yes ❑ No ❑ ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary [I Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only [IMobile Food Vehicle--Make Vehicle Type Go Registration# License# Sticker# # Make Vehicle Type Calor ❑ Mobile Food Prep Unit Sticker# Registration# License# ❑ to Ice Plant ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand ❑ Special Event Dates of operation from to DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 13 Hazardous Waste Generator-----------Tans Generated Per Year ❑,RecyclelExempt System(2299) ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered PermittingFa cility------------------ ❑ Conditionally Authorized(CA) ElConditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-B Household Hazardous Waste JABOVEGROUND',STORAGE TANK FACILITY(AST)(2390) Number of AST �!UNDERGROUND',STORAGE TANK(UST)PROGRAM(2300)Use USIA and B fo HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700)Use Employee Housin /Labor Camp Apelication Farm SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility— 11 Pool ❑ Spa [jOut of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) [I Poultry Farm------Maximum number of birds 11 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I#of Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT_ g � FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#G' PERMIT VALID t0 __ ❑ Food Handler ❑ Check# 'AMOUNT PAID Date 01 INVOICE# ❑ Cash REVIEWED 6Y ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11!15/07