Laserfiche WebLink
SAN JOAQUIN COUNTY E 1RONMENTAL HEALTH DEPAR'. .NT <br />MASTERFILE RECORD INFORMATION FORM <br />g New EH Program at Existing Facility <br />Facility ID <br />ONew EH Program and New Facility <br />Program Record ID <br />Facility Address 51 N.1 <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />1lMobile Food Vehicle --Make <br />-71.1(r -ri 3;f - Oa_Kifct.(J: s-- F_D(4- I <br />and specify size, number of units and pertinent information.) <br />Square Footage Food Handlers Course required: YES if No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # J FL! Iv ;),(3 Sticker # <br />Vehicle Type Color <br />License # Sticker # <br /> to 0 Ice Plant 0 Produce Stand <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <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-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br /> <br />0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />0 Package Treatment Plant <br />0 Chemical Toilets ----Number of Units <br />Dumpsters > 20 cu yd (# of Units) <br />Ag/Cannery Waste Site <br />Process/Recycle Facility O CIA La <br />Farm/R <br />Sludge!, <br />0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Lim ed <br />0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 6ciks€4400_, P.-Ck <br />•• ..\.' -‘c), 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 Ct.41 (2 \ te- SA A..) t7E- g-S Day Ph 2nci (go 2 /c, 5 ;- Night Ph 20q 6,-o.,2 70 <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br />0 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 VehicieRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care <br />Transfer Station <br />License # Capacity Vehicle # <br />te;:ts <br />latvie,a <br />\\C\,le%rrtipetft-e‘.,‘.0 <br />PROGRAM ELEMENT t - FEE <br /> <br />0 Surch <br />INSPECTOR # ' \,` •^ ' i PERMIT VALID 7 <br /> to <br />11 Check # ' ' i c„,1 /4:-, c t ‘D.,--'1'.' AMOUNT PAID I <br /> <br />Date <br />Cash REVIEWED BY , ' ACCOUNTING OFFICE <br />rge EE 0 Other FEE <br />INVOICE # 2 -P72. <br />Date 7 <br />0 Food Handler <br />48-02-034 MASTERFILE RE ORD FO MATION PINK <br />1/2 3/13