Laserfiche WebLink
SAN JOAQUIN COUN N ONMENTAL HEALTH DEI;A_RTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility <br /> ew EH Pro ram and New Facility <br /> ILFacility H) C O [ -0 Pro ram Record ID <br /> Facility Address ttwio✓1 St <br /> (Please Check the appropriate description and specify size,number and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage <br /> ❑ Commissary El Dry storage only Food Handlers Course required: YES El No Elg y ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments <br /> ❑ Mobile Food Vehicle-----Make 11 Prepackaged Goods Only <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit-Make License# Sticker# <br /> Registration# Vehicle Type Color <br /> ❑ Temporary Food Facilityp License# Sticker# <br /> -----Dates of operation from to <br /> ❑ Special Event --Dates of operation from El Ice Plant <br /> DAIRY PROGRAM(2000) to ❑ Produce Stand <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUP A ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year <br /> 11CRT Offsite Handlers (2218) 11Silver Onl ❑ Recycle/Exempt System (2299) <br /> Facility <br /> y(2222) Appliance Recyclers(2217) <br /> Tiered Permittin <br /> g ty- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) <br /> El STORAGE TANK FACILITY(AST)(390)le xed NIu ber of AST Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee IIousing(2700) Use E�loyee Housing/Labor a <br /> Cm Pplicaiion Form mail or Exempt Institution-------Number of Units <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 ofPools/Spas at Facility E]pool <br /> ❑ Spa Out of Service Pool/Spa Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm -------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Kennel <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) ❑ Permanent Cosmetics(4122) <br /> ❑ Pumper Vehicle-Registration# License# <br /> El Pumper Yard Capacity Vehicle# <br /> ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station <br /> ELWaste Tire Facility ❑ Compost Facility C1 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> El Refuse Vehicles--Number of Units <br /> ❑ Dumpsters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Farm/Ranch Cleanup Site <br /> ❑ Primary Care 11 Acute Care El Skilled Nursin <br /> 11 Transfer Station g C3 Large Generator 13 Small Generator 11 Limited Hauler <br /> ❑ Veterinary Clinic ❑ Common Storage Facility <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS FID 46-02-003 Blue Application❑Form <br /> 0 - El 11 -60------❑ >60 generators <br /> CONTACT PERSON EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> Flo <br /> RAM ELEMENT q?`' D FEE <br /> ❑ Surcharge FEE ❑ Other FEE <br /> TOR# Q U CG PERMIT VALID <br /> to ❑ Food Handler__ <br /> k# AMOUNT PAIDDate INVOICE#REVIEWED BY ,Tr` ]&'Tl� ACCOUNTING OFFICE <br /> 48-02-034 <br /> 2 Date 7 7 D b <br /> 10/6/2003 Masterfile Record Pink <br />