Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ew EH P <br />Facility ID PAD ;I -'x-71 el Program Record ID <br />Facility Address <br />(Please check the appropriate description and specify slze, number of units ant <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity_ Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ w/Meat Market only <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 <br />❑ Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk <br />0 <br />to <br />C PA <br />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 Exen <br />Employee Housing (2700) Use Employee Housing/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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds _ <br />❑ Spa ❑ Out of <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 Coord (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 />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Si <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Fac <br />11Refuse Vehicles Is of units) ❑ Dumpsters > 20 cu yd <br />LF <br />Handlers Course required: YES ❑ No ❑ <br />(ding Machines Number of Units <br />)Is Departments ❑ Prepackaged Goods Only <br />Color <br />_ Sticker # <br />_ ❑ Ice Plant ❑ Produce Stand <br />❑CFO ❑A❑B <br />of Containers in Multi -Head Unit_ <br />❑ Program 3 Facility <br />PBR (2231) ❑ PBR HHW (2236) <br />Institution ----Number of Units <br />ROL (3000) <br />0 NPLISEP Cleanup Site ❑ UIC Site <br />p 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 />lacity Vehicle # <br />Toilets --Number of Units <br />❑ Sludge/Ash Site <br />y ❑ CIA Landfill Site <br />of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generato ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 2-10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use <br />CONTACT PERSON <br />PROGRAMi <br />Day Ph Night Ph _ <br />❑ Surcharge - E ❑ Other <br />INSPECTOR#�S� PERMITVALID-7� t0 <br />❑ Check # AMOUNT PAID T�"t,r�t.[..fJ� Date <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />1/23/13 <br />❑ Food Handler <br />INVOICE# ,2L'1- <br />Date 713/Iq <br />