Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FOR11I <br /> VkNew EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ,ID F A 00115 1 Pro ram Rccord ID P"S3 S fA1L4 <br /> Facility Address 0 <br /> (Please Check the appropriate description and specify size,number of un sand 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 it 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 Muld-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator— Tons Generated Per Year ❑ Recycle!Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) 1 ❑ 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(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ IloteUhiotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Frnplopee Housinc/La6or Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAronmeatal Assessment ❑ UST-CAP Site ❑Local IlW Cleanup Site. ❑NPL!SEP Cleanup Site 11 UIC site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL IIEALTN PROGRAM(3600) <br /> Number of PooWSpas at Facility. ❑ Pool ❑ Spa ❑Out of Service Poolfspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kenuel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I Pumper Vehicle—Registration# License# Capacity Vehicle <br /> ❑ Pumper Yard El Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site 11 Sludbe/Ash Site <br /> 3Vaste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vebides—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Sife <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Linuted Hauler <br /> ❑ Transfer Station ❑Veterivary Clinic ❑ Common Storage Facility--11 2- 10 Ell] -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PII,1; FIID 46-02-003 Blue Application For-rn <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> t� I <br /> PROGItANt ELEMEN-T f FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �l�d PERMITVALID to El Food Handler <br /> ❑ Check f AINIOUNT PAID Date INVOICE# <br /> 0 Cash REVIEWED BY ACCOUNTING OFFICE ~r Date >� <br />