Laserfiche WebLink
w <br /> Ah Ak <br /> SAN JOAQUIN COUNT ls ONMENTAL HEALTH DEP T NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> El New EH Pro am at Existing Facility []New EH Program and New Facility <br /> Facility ID 1—A 0 a O5 /t Program Record ID <br /> Facility Address 3 6 W, A 1,", -1 <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) <br /> HAZARDOUS WASTE PROGRAM(2200) <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 HousinglEabor Camp Application Form <br /> SITE MITIGATION(2900) DO) <br /> ❑ Environmental Assessment C 'Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW SiteC Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGF <br /> Number of Pools/Spas at Facility TRUCKING a ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(41 - j14.0,18-0. <br /> ❑ Poultry Farm----Maximum nur e E L STOCKTON AG TRANSPORT ❑ Kennel <br /> TATTOO, BODY PIERCING,PERK RENE SCHMIDT TERMINAL <br /> 36 W. MATH WAO <br /> ❑ Tattooing(412 1) rene@silvatrucking.com FRENCH CAMP, CALIF. 95231-9753 ermanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) OFFICE(209)982.1114 MAILING <br /> ❑ <br /> Pumper Vehicle--Re stration# P.O. BOX 1449 Vehicle# <br /> P _ FAX (209)982-1431 FRENCH CAMP, CALIF. 95231 <br /> ❑ Pumper Yard U Package Treatment Plant u Lnemtcai i ouets-------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/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------13 >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 ELEMENT -I � FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �d�/ PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date — INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICEU _ a)Date <br /> 48-02-034 Masterfile Record Pink <br /> 10/6/2003 <br />