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SAN JOAQUIN COUNTY EN1 )NMENTAL HEALTH DEPARTM r MASTERFILE RECORD INFORMATION FORM El New EH Program at Existing Facility New EH Program and New Facility Facility ID Facility Address n n G Program Record ID Piztls-cf,2)- 6. <An 3{1 . (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No 0 CI Commissary CI Dry storage only Cl with Food Preparation Illvencling Machines Number of Units El Retail Market----Square footage 0 w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only obile Food Vehicle --Make 01\-elq Vehicle Type Color Registration # License # L(7 (J'2'2_ t_. \ Sticker # CI Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # CI Temporary Food Facility --Dates of operation from CI Special Event—Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: El CalARP Program 0 Program 1 Facility CI Program 2 Facility El Program 3 Facility Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > CI CA (2232) El CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms CI Other CUPA Program HOUSING PROGRAM (2400) CI Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) CI Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility I=1 Pool 0 Spa CI Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) CI Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) CI Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) El Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper Vehicle Registration # License #Capacity Vehicle # Pumper Yard CI Package Treatment Plant 0 Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) CI Landfill 0 Transfer Station El Ag/Cannery Waste Site El Waste Tire Facility 1:1 Compost Facility CI Process/Recycle Facility CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) MEDICAL WASTE PROGRAM (4500) 1:1 Primary Care 0 Acute Care El Skilled Nursing 0 Large Generator El ID Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2- 10 PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form 111 Other FEE El Food Handler INVOICE# 3 0 /32 — Date MASTERFILE RECOF3O INFORMATION PINK to CI Ice Plant ID Produce Stand El Sludge/Ash Site CIA Landfill Site Farm/Ranch Cleanup Site Small Generator CI Limited Hauler El 11-60 LI >60 generators 4-O2-O34 EMERGENCTIFICATa FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON C10/10-,110 eAlt 0 Day Ph 2.01 211 '101 1' PROGRAM ELTENT \ k.to FEE OD C1 Surchar. INSPECTOR # )ig 6ik PERMIT VALID 9••• to F E CI Check # AMOUNT PAI 6 Date Cash REVIEWED BY ACCOUNTING OFFICE Night Ph -2.09 °ti 1/23/13