Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Pr LXisting Facif!X ❑New EH r and New <br /> Facilit `� o ram Re rd ID a <br /> Facility Address I ' <br /> (Piease heck the appropriate description and specify size, umber of uo' s and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yrs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation Wending 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# Slicker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> to ❑ Ice Plant <br /> ❑Temporary Food Facility---Dates of operation from ❑ produce Stand <br /> [3 special Event —Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> El Grade A Dairy ❑ Grade B Dairy ❑Milk Dispeaser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAOUS WASTE PROGRAM(2200)' t <br /> azardous Waste Generator.--Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2216) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility [I Permit-By-nditionaly Authorized CA)Ru a Fixed Unit ❑Permit-By-Rule H 0 Conditionally ousehpt old Hazardous Waste <br /> ❑ ABOVEGROUNDSTORAGETANK FACILITY(AST)(2390) NumberofAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B/arms <br /> HOUSING PROGRAM(2400) <br /> [3 Jail or Exempt Institution Number of Units <br /> ❑Hotel/Motel—Number of Units <br /> Employee Housing(2700)Use EmployeeIfausiaK bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ElEnvironmental Assessment [3UST•CAP Site 13Local HW Cleanup Site. 11NPUSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑non-NPWEP Cleanup Site ❑RWQC13 Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas al Facility ❑Pool 13 Spa Out of Service Pool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) - - ❑Kennel <br /> ❑Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑permanent Cosmetics(4122) <br /> ❑Tattooing(4121) ❑Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) ac <br /> Ca il Vehicle# - <br /> ❑ Pumper Vehicle—Regishation# License# Capacity <br /> ❑FackageTreatmentPlant ❑ChernicalToilets—Numbuof Units <br /> ❑ Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ Slud e/Ash Site <br /> El Landfill C1 Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Process/Re cle Facility 11CIALandfrD Site <br /> [I Waste Tire Facility 13 Compost Facility cY ❑ Farm/Rauch Cleanup Site <br /> ❑Refuse Vehicles—Number of Units (3Dumpsfers>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care 13 Acute Care ❑ Skilled Nursing 13 Large Generator D Small Generator ❑ Limited Hauler <br /> 13 Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10—❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PB'S EMP 46-02-003 Blue Appricarion Form <br /> GE <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON 7 <br /> _Y [_p(,,*'l�r'✓� Day Ph Night Ph <br /> PROGRAM ELEAIErNT FEE OL ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to 3 ❑ Food handler r <br /> ❑ Check# OUNT PAID Date INVOICE# <br /> ❑Cash REVIEWED BY <br /> ACCOUNTING OFFICE J2= Date <br /> 1 Record fink <br />