Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />® New EH Proqram at Existing Facility ❑New EH Program and New Facility <br />Facilitv ID Program Record ID <br />Facility Address 318 W Main St, Ripon, CA 95206-3341 <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />ReSA17- <br />Ce,,/VP® <br />ocr 12 <br />SAN J0 Z018 <br />gQUI cOU <br />HSL H,0 PgRTTAN'Y <br />A�IFNr <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 />(2 Retail Market—Square footage 8,500 ❑ with Meat Market only ❑ Multiple Departmentsli Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit Make Vehicle Type _ <br />Registration # License # Slicker # <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Color <br />_ ❑ Ice Plant <br />❑ Produce Stand <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 HousinalLabor 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds _ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehlcleRegistration # 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) ❑ Dumpslers > 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 112 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON Angela Jolles Day Ph 151-;il1-bUUU Night Ph <br />PROGRAM ELEMENT_ FEE ❑ Surcharge F E ❑ Other FEE <br />INSPECTOR# c� PERMIT VALID t0 X031 i 11 Food Handler <br />E3 Check # 3o I AMOUNT PAID � 7 Q� Date 1M !4 INVOICE # 31 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE i Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />