Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD'IN>+ORMATION FORM <br /> ew EH Program at Existing Facility []New EH Program and New Facility <br /> Facilit ID Pro ram Record H) �c '/ <br /> Facility AddressIgRno (,3, ,(�011t �. 2 <br /> (Please Check the appropriate description and specify sing 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 /> ❑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# w <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 Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ti GUPA ❑ State Facility Surcharge(2349) <br /> HAZARDOUS WASTE PROGRAM(2200) � <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle#Exempt System(2299) <br /> ❑CRT Offsite Handlers(22-18) ❑ Silver Only(2222) ❑ Appliance Recyclers(2117) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-Dy-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> }ABOVEGROUND STORAGE'YANK FACILI'T'Y(AST)(2390) Number of AST �0 ow_UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and Blorms I <br /> HOUSING PROGRAM(2400) <br /> ❑Ilotel/Motel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee ffousinglLabor Camp_Awfication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13 Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. U NPLISEP Cleanup Site L3UIC Site <br /> ❑Abandoned Il1V Site ❑non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of SerAcg 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(412 1) ❑ 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/CanneryWaste Site ❑Sludge/Ask Site <br /> ❑Waste tare Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill.Site <br /> ❑Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch 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—[] 2-10 ❑ 11-60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EMD 45-02-003_Blue Applicalian Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANOIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRo(;RAAI ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> IIYSPECI OR# PERMIT VALID . to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE#i <br /> 11Cash REVIEWED BY U I'0 AccouNTING OFFICE Date ZZ Le5l Z 62 <br />