Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTP-RFIL.E RECORD INFORMATION FORM <br /> ❑New EH Pro at Existing Facility Mew EH yP��ro and New Facility <br /> FacilityID � OL91��3 ::�.. : : Program Record ID plo <br /> Facility AddressEo-:2�VL6 Ad <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❑ <br /> ❑ Commissary ❑Dry storage only ❑ with Food Preparation - ❑Vending Machines.—Number of Units <br /> ❑ Retail Market----Square footage ❑with Meat Market only ❑MultipleDe`jialtrtieats. ❑Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----MakeVehicle 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 /> IIAY,NRDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous NVaste 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 Ilazardous 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 IlousinKabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site ❑NPLtSEP 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 <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑ 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(4400) <br /> ❑ Landfill • ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ SludgelAsh Site <br /> ®Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles.—Number of Units ❑Dumpsters>20 ar yd—Number 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-0 2-10 ❑ 11-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS rACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Y�� FEE 11Surcha�rrEe FEE 11Other FEE <br /> INSPECTOR# Lk (D °-� PERMIT VALID to V13DZD 4�2 ❑Food Handler <br /> ❑ Cheek# AMOUNT PAID j Date INVOICE# <br /> El Cash REVIEWED BYAccouNnNG OFFICE Date "r/3a D <br />