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SAN JOAQUIN COUNTY EN` Ol . _ENTAL HEALTH DEPARTI&N- <br />MASTERFILE RECORD INFORMATION FORM <br />( New EH Program at Existing Facility 42ew EH Program and New Facilitv <br />Facility ID r:4 CC /,Si'j 8 ~� Program Record ID 75 - <br />Facility Address -moi L 0J- Fre-m e n f >t <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 Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines --Number of Units <br />❑ Retail Market ---- Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make Vehicle 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 ❑ Ice Plant <br />❑ Special Event --Dates of operation from to ❑ Produce Stand <br />DAIRY PROGRAM (2000) <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 />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution ------- Number of Units <br />Employee Housing (2700) Use Employee HousinglLabor 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 />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />TATTOO. BODY PIERCING PERMANENT COSMETIC PROGRAM (4100; <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # <br />❑ Pumper Yard ❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacit} Vehicle # <br />❑ Chemical Toilets ------Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />E"Vaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units ❑ DumpSlers > 20 cu yd ----Number of Units — <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02-10- 10------- ❑ 11 -60-- <br />PUBLIC <br />60 -- <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />❑ Limited Hauler <br />❑ > 60 generators <br />PROGRAIII ELEMENT I� 4U FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # C'C(LC PERMIT VALID to ❑ Food Handler <br />❑ Check # ANIOUNT PAID Date INVOICE .= <br />❑ Cash REVIEWED BY b r5 ACCOUNTING OFFICE Date 41 AS <br />48-02-034 Masterfile Record Pink <br />10/6,'2003 <br />