Laserfiche WebLink
SAN JOAQ JIN COUNW VVIRONMENTAL HEALTH DEPSTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facili New EH Program and New Facilit <br /> Facility ID /j` Program Record ID �R <br /> Facility Address [tu(%t. -43 <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 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 Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ <br /> CUPA ❑ State Facility Surcharge(2399) 7 -THAZARDOUS WASTE PROGRAM(2200) )7 - -,) <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 Unit ❑ Permit-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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP 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 Pool/Soa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm--Maximum number of birds ❑ Kennel s <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 ❑ SludgelAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (#of units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup jSite ,MEDICAL WASTE PROGRAM(4500) <br /> 13Primary Care ❑ Acute Care 11Skilled Nursing ❑ Large Generator F-1Small Generator ❑ Limited HauleElTransfer Station CIVeterinary Clinic 1:1Common Storage Facility ❑ 2-10 El11 -60 11 >60 generate <br /> PUBLIC WATER SYSTEM PROGRAM (46D0)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph <br /> PROGRAM ELEMENT. FEE ❑ Surchar a FEE ❑ Other FEE <br /> INSPECTOR# ` lV". ' I;'7✓' PERMITVALID I ) t0 , 11 Food Handler • <br /> ❑ Check# TT AMOUNT PAID ' Date I INVOICE# _ <br /> ❑ Cash REVIEWED BY _"l,:'�- ACCOUNTING OFFICE ,� Dates_4TFLA <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />