Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL I DEPARTMENT <br /> MASTERFILE RECORD INFORMATIO ORM <br /> 11 New EH Pro am at Existing Facility New EH Proand New Facility <br /> FacilityID a Program Record ID D 02 <br /> Facility Address / 20 / 14✓ ::r ('iY g53 7{� <br /> (Please Check the appropriate description and specify EjK�,number of units and perlineot information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food IIandlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑Drystorage 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 /> [3Special 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-Ifead Unit <br /> COPA [:] State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) - I <br /> ❑Hazardous Waste Generator Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑Appliance Recyclers(2217) <br /> Ticred Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit "t-By-Rule Household Hazardous Waste <br /> JJAABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST olvws� <br /> UNDERGROUND STORAGE TANK(US7)PROGRAM(2300)Use UST A and B f000���nnneees��� <br /> HOUSING PROGRAM(2400) _ <br /> ❑ IIotellMotel—Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employ"Rousing(2700)Use Fmplopee 7faasine4,gbor Camp Anplica(ion Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑Loral IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IRV 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 11 pool 13 spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [3 Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site - <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--El 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIES F.11D 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELFNIFNf FEE -' ❑ Surcharge Fee ❑ Other FEE <br /> 1NsrEcr0R# PERMIT VALID . to ❑ Food Ifandler <br /> 13 Check 11 ATIOUNTPAID Date INVOICE# <br /> ❑ Cash REViEwEDBY ACCOUNTING OFFICE Date <br /> alae�4 RKmI Sink <br />