Laserfiche WebLink
y ONew EH Program and New Facility <br />acility ID <br />SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR1 NT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at ExistingFacility <br />r4 0- Program Record ID <br />Facility Address 6010 S. ...Sn_c,co—vt r\-ko toat ( A qs:,c) <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 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # License # <br />‘0,.Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />R 4.celVen <br />— <br />sati„A 2 5 2018 <br />eivviR QuIN co ovry <br />0E.p nfrAL <br />Food Handlers Course required: YesRligttlE <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />a. (p 4 Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />0 w/Meat Market only <br /> Vehicle Type <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />Cu PA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) _ <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <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 arc , 0, Os, _ Day Ph 9 ‘,. 54R- 35S-Night P(. <br />0 Kennel <br />License # Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />0 Small Generator 0 Limited Hauler <br />0 11 - 60 0 > 60 generators <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PROGRAM ELEMENT L0 FEE c/ <br />INSPECTOR # / ,D PERMIT VALID <br />0 Check # AMOLtNT PAID <br />0 Surchar e FE 0 Other FEE <br />to 2-3 <br />Date <br />0 Food Handler <br />INVOICE # <br /> c9 <br /> <br />Cash REVIEWED BY <br /> <br />4-02-034 MASTERFILE RECORD I FORMATION PINK <br />1/23/13 <br />ACCOUNTING OFFICE Date