Laserfiche WebLink
SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEP�ARVENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Progr m and New Facility <br /> Facility ID 1 Program Record ID <br /> Facility Address' 0 c� a c , <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 /> 1:1 Retail Market----Square footage ❑ wlMeat Market only E3 Mul iple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type 1 Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser- umber-of Containers in Multi-Head Unit <br /> CU�PA <br /> IT lyazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235, 2h7) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use USIA and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exerr pt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp_Application Farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ' ElNPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site Elnon-NPLISEP Cleanup Site ❑ RWQCB Clearup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of ervice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> El Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic I Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Sipe ❑ StudgelAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Fac`Iity ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles p or Units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL,WASTE PROGRAM (4500) <br /> El Primary Care El Acute Care El Skilled Nursing El Large Generator ❑ Small Generator El Limited Hauler <br /> El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue App licati n Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY IANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM EL ENT C( FEE r El Surcharge FEE E ElOther FEE <br /> INSPeCTOR# { 1( �iE PERMIT VALID t0 ❑ Food Handler <br /> ❑ Check# A OUNT PAI Date I INVOICE# <br /> ❑ Cash REVIEWED BY f' ACCOUNTING OFFICE Date <br /> 4a-02-034r y MASTERFILL RECORD INFORMATION PINK <br /> 1123/13 lv I l <br />