Laserfiche WebLink
SAN JOAQUIN COUNTY JIRONMENTAL HEALTH DEPS F ]ENT <br />MASTERFILE RECORD INFORMATION FORM <br />® New EH Program at Existing Facility ❑New EH Pro <br />Facility 05q cC,)-y-76b Program Record ID 7A <br />Facility Address 2-80y A -,-)-TC) Z -A v,,Ay Sit <br />(Please check the appropriate description and specify size, number of units and X <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Fo <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑, <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ M <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from to _ <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -I <br />CUPA j <br />13 Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2" <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ Jail or Exem <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CON <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Clear <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of S <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # C <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic <br />SOLID WASTE PROGRAM (4400) <br />and New Faci <br />YO'q2 <br />Handlers Course required: YES ❑ No ❑ <br />iding Machines Number of Units <br />pie Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />❑ Ice Plant ❑ Produce Stand <br />❑CFO ❑A❑B <br />mber of Containers in Multi -Head Unit <br />❑ Program 3 Facility <br />7) ❑ PBR (2231) ❑ PBR HHW (2236) <br />pt Institution ----Number of Units <br />TROL (3000) <br />❑ NPL/SEP Cleanup Site ❑ UIC Site <br />up Site ❑ Water Quality Remediation Site <br />Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Body Art Facility -Single Use (4120) <br />❑ Body Art -Temp Event Mobile Facility (4131) <br />ipacity Vehicle # <br />Toilets ----Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Si e <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles (# of Units) ❑ Durnpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicatic <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR # <br />❑ Check # A <br />❑ Cash REVIEWED BY <br />48-02-034 <br />1/23113 <br />Day Ph W1. <br />I FEE ❑ Surcharge <br />PERMIT VALID to <br />PAID Date <br />ACCOUNTING OFFICE <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />❑ Small Generator ❑ Limited Hauler <br />2-10 ❑ 11 -60 ❑ > 60 generators <br />Fonn <br />RPROGRAM <br />-1� Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE #� <br />Date I/S <br />MASTERFILE RECO4kD INFORMATION PINK <br />