Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> El New EH Program at Existinq Facility -ograrn and New Facility <br /> EH Pi <br /> Facility ID Program Record ID <br /> Facility Address 37ft t> <br /> (Please check the appropriate description and specify size. number of units <br /> and pertinent inforl-nation.) <br /> FOOD PROGRAM (1600) <br /> El Restaurant: SeabngCnpaody_____ Square Footage Food Handlers course required: YES El No <br /> [] Commissary [] Dry storage only [] uiihFood Preparation []VenclingMachines Number ofUnits <br /> [] <br /> Retail Market----Square footage [] p/k8ee1 Market only [] Mu|dp|o Depenmor4o [] PrepackagedGoodsOnly <br /> --------- <br /> [] Mobile Food Vehicle–K8oke Vehicle Type Color <br /> — ` <br /> Registration# Lioense# ��-------dcker# <br /> [] Mobi}eFoodPrepUnit–Make Vehicle Type Color <br /> Registration# License# <br /> Sticker# <br /> [] Temporary Food Facility --Dates of operation from to [] Ice Plant [] Produce Stand <br /> [] Special Event <br /> Dates ofopeoperation from �o 1-71 CFO [] A [] B <br /> DAIRY PROGRAM (zoun) <br /> [] Grade A Dairy [] Grade B Dairy [] Milk Dispenser-Number ofCnntaine/s in Multi-Head Uni1_____ <br /> CUPA <br /> Hazardous Materials Business Plan (18OO) Numberofohemica|s. <br /> [] Ca|ARP Program [] Program 1 Facility [] Program 2 Facility El Program 3 Facility <br /> [] Hazardous Waste Generator (22OO)----------� Tons Generated Per Year <br /> Tiered Permitting Facility '' [ CA 2232) [ CE /2233 2234 2235 2237) [] PBR (223|) [] PER HHVY ,2230) <br /> [] AbovegroundStorage Tank Facility (AST) (28O0) Numb*rofAGTo________ <br /> [] Underground Storage Tank Program (UST) (22100) Use <br /> [] Other CUPA Program <br /> HOUSING PROGRAM \24D0) <br /> [] HoteVMote|------Numbe/ofUnits [] Jail orExempt Institution ----Number ofUnits <br /> Employee Housing (27OO) Use Employee PiousinglLabor Camp Application Form --------- <br /> SITE MITIGATION (290O) OOO) <br /> [] Environmonta|`4ssesument [] UST-CAP Site [] Local HW Cleanup Site [] NPL8EPC/oanup Site El U|C Site <br /> [] Abandoned HVVSite [] non-NPL/SEP Cleanup Site [] RVVQCB Cleanup Site [] Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3OOO) <br /> Numhe/ ofPoo|n/Span at Facility [] Pool [] spa [] Out ofService Pool/Spa [] Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4OUO) <br /> El pouuryrerm---'Mnx/mumnumberofbirde [] Kennel <br /> TATTOO, BODY PIERCING.PERMANENT COSMETIC PROGRAM (41OO) <br /> LJ Body Art Practitioner Reg (411O) [] Mechanical DSPSNotification (4115) [] Body Art Facility-Single Use (412O) <br /> [] Body Art Facility-Sterilization (4121) [] Body Art TempEvent Co'on] (413O) [] Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM (42OO) <br /> 0 PumperYohidoRegiu8'ahon Linense# — Capacity Vehicle# <br /> [] PumporYard [] Package Treatment Plant [] Chemical Toilets----NumhenofUnits(4400) <br /> ESOLID WASTE PROGRAM l <br /> [] LandfiU [] Transfer Station [] Ag/ComneryVVaste Site [] Sludge/Ash Site <br /> [] <br /> Waste Tire Facility [] Compost Facility [] Pnoces*/Renyo|eFaui|ity [] CIA Landfill Site <br /> [] <br /> Refuse Vehicles on"s) _______ [] Dumpste/s> 20 cu yd o.-t, [] Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (45OV) <br /> [] Primary Cum [] Acute Care [] Skilled Nursing [] Largo Generator [] Small Generator [] Limited Hauler <br /> [] Transfer Station [] Veterinary Clinic [] Common Storage Facility [] 2 10 [] 11 UD [] > 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use Fo/n/ <br /> EMERGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br />