Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD'INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Progmm and New Facility <br /> Facility IDB Program Record ID <br /> Facility Address I% ' <br /> (Please Check the appropriate description and specify LIT,number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel 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 /> ❑Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - - <br /> ❑ Grade A Dalry ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) t <br /> [IHazardous Waste Generator Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ rmit-By-Rule Household Hazardous Waste <br /> /ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B to / <br /> HOUSING PROGRAM(2400) - <br /> ❑BoteUMotel—Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee flousiargAbor Camp APPUcalroa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site_ ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW 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 ❑Pool ❑Spa 11 Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) ' <br /> ❑ 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 [3 <br /> 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 ❑Process/Recycle Facility ❑ CIA.Landfill Site <br /> ❑Refuse Vehicles-Number of Units ❑Durnpsters>20 cu yd—Number of Units ❑Farm(Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care - ❑Acute Care ❑ SkilledNursing ❑Large Generator ❑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 PWS EflD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT ?- FEE ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR#—� PERMMrf VALID . to ❑Food handier <br /> ❑ Checker AMOUNTPAiD Date INVOICE# <br /> ❑ Cash REVIEWID BY AccowmNC OFFICE Date I <br /> +o..(.1.Rlr Piny <br />