Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIYLENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New Eli Program at Existing Facility New EH Program and New Facility— <br />Facility <br />acilityFacilit y ID Program Record IDP <br />Facility Address% 3 5 N N` 9 <br />(Please Check the appropriate description and specify size, 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 <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 />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />IIAZARDOUS WASTE PROGRAM (2200) 3 <br />❑ Hazardous 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 Uniteirnit-By-Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST / %DOD I LG 6'v <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B orms <br />HOUSING PROGRAM (2400) <br />❑ Ilotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employ" housing (2700) Use Fmpleyee IfoasinglLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local IIW Cleanup Site • ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IiW 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 ❑ Out of Service PoollSpa ❑ 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 / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle 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 />11 Primary Care ❑ Acute Care 11 Skilled Nursing 11 Large Generator [3 Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --0 2 - 10 ❑ 11- 60 ------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PITS F11D 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />�XTTA rr tncn enlV Dav Ph Night Ph <br />