Laserfiche WebLink
—' em <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit•ID 7A Pro ram Record ID �s�'�9 6 S <br /> Facility Address <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 11 <br /> ❑ Commissary ❑ Dry storage only 11with Food Preparation ❑Pending 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 f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ 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 HousinzTgbor Camp Applicadon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local 11W Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned MY Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site 1❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 ❑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 /> ❑ Tattooing(4121) ❑Body Piercing(4 120) ❑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(440 0) <br /> 11 Landfill 13 Transfer Station ❑Ag/Cannery Paste Site ❑ Studge/Ash Site <br /> PT 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 /> ❑ Primary Care ❑Acute Care ❑ Skilled'Nurs'mg ❑Large Generator D Small Generator ❑Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-1 O ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM_ PROGRAM(4600)Use PWS EHD 46-02-003 BlucAppHcation-Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT U FEE ❑ Surcharge FEE' ❑ Other FEE <br /> INSPECTOR# T PERIvIITVALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY Z � ACCOUNTING OFFICE !//� Date V 4�Zv(J <br />