Laserfiche WebLink
Adak <br /> SAN JOAQUIN COUNTY EN ONAENTAL HEALTH DEPAR T <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Program Record ID 0 q Zjo <br /> Facility Address 1-0 -(_�i °> NlY P r� w V,,` � TA-�,` <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 13 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 11 <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 /> 11 Hotel/Motel-------Number of Units ElJail 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 /> El Environmental Assessment ❑ UST-CAP Site El Local HW Cleanup Site 11NPL/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 11 Pool El Spa El Out of Service Pool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm--------Maximum number of birds 1:1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill [I Transfer Station El 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 /> El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator 11 Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----02- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use XVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON `� Day Ph Night Ph <br /> PR0GRA`1 ELEME �NT t t7 FEE 0 � El Surcharge FEE ElOther FEE <br /> INSPECTOR# �j�t` PERMIT VALID 9(/CJD 10 S to 1��30/D 1p ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY AccoUNTING OFFICE Date <br /> Masterfile Record Pink <br /> 41-02-034 <br /> 10/6/2003 <br />