Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ® New EH Program at Existing Facili ❑New EH Pro ram and New Facility <br /> Facility ID 2, ` Program Record ID KJ� <br /> Facility Address A v �J I T�- L OD i C'14 CJS--? 0 <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,0 No ❑ <br /> El Commissary 0 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 HousinglLabor Camp Application Foran <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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds _ ❑ Kennel C <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) PAYMENT <br /> ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmc�lip MvF® <br /> LIQUID WASTE PROGRAM(4200) 11���� <br /> ❑ Pumper Vehicle Registration# _ License# Capacity VehichPRA g 7019 <br /> 1:1 Pumper Yard El Package Treatment Plant ❑ Chemical Toilets ----Number of Units H <br /> SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUNTY <br /> V .ONMENTAL <br /> ❑ Landfill <br /> El Station ElAg/Cannery Waste Site ❑ Sludge/ 0EpARTN',,ENT <br /> ❑ Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility El CIA Lan fill Site <br /> ❑ Refuse Vehicles f#of units) ❑ Dumpsters> 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 ❑ 2 - 10 ❑ 11 -60 ❑ >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 �� h t� ft I 1N)�- Y 9' Da Ph Uq 1 2 Night Ph � 0 <br /> iL <br /> PROGRAM ELEMENT FEE 23 ❑ Surcharge FEE El Other FEE <br /> INSPECTOR# (o Z1 PERMIT VALID tO 12,e2 ❑ Food Handler <br /> . Check# 1'2--4—� AMOUNT PAID x — Date INVOICE# <br /> ❑ Cash REVIEWED BY �/ ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />