Laserfiche WebLink
SAN JOAQUIN COUNTY E ' IRONMENTAL HEALTH DEPAR' . NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ZNew EH Program and New Facility <br /> Facilit ID Zj Program Record ID3 <br /> Facility Address I / L - . Firms 9e �frr : ,t .f, ( C �k c `x'5203 <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 ❑ w/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 ❑ Produce Stand <br /> ❑ Special Event--- Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM ( 2000 ) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser - Number of Containers in Multi - Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan ( 1900) Number of chemicals : <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator (2200 ) -- -------- > Tons Generated Per Year <br /> ❑ Tiered Permitting Facility --- - --- > ❑ CA (2232) ❑ CE (2233 , 2234 , 2235 , 2237) ❑ PBR (2231 ) ❑ PBR HHW (2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program ( UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <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 ❑ NPL/SEP 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 ❑ 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 /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121 ) ❑ Body Art Temp Event Co -ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131 ) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper VehicleRegistration # 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 (# of units) ❑ Dumpsters > 20 cu yd (# 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 EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELF" T � � � 1 � F ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR # e 2 PERMIT VALID to ❑ Food Handler <br /> ❑ Check # AMOUNT PAID Date � 2 INVOICE # <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORP INFORMATION PINK <br /> 1 /23/13 <br />