Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> R�Wew EH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID rA on 139,r, Program RecordID 2aS31 / <br /> Facility Address 1 Gtr LCvI:se ' ,+" o,l , <br /> (Please Check the appropriate description and specify sue•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food HandlersCourse required: YES 11No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle 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(20W) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-liead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator----- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ 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 Hazardous 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 /> ❑ Ilotel/Motel Number of Units ❑Jail or Exempt Institutioa Number of Units <br /> Employee housing(2700)Use F,mploree Housing/tabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site• ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ AbandouPd IIW 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. ❑P901 ❑ 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 ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu 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--[] 2-V) ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'SFfID 46-02-003 Blue Application Forrn <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELERIENr O FEE_ ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID__ to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date J INVOICE I# <br /> ❑ Cash REVIEWFDBY ACCOUNTINGOFFICE i Date <br />