Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New Ell Program at Existing Facility ❑New Ell Program and New Facility <br /> Facilit 'ID j C _, Program Record ID <br /> Facility Address — — /�� Amw!�t G�,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 Food Handlers Course required: YES 11 No El <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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 /> El Temporary Food Facility—Dates of operation from to El lee Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Pernut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number oCAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B(arms <br /> HOUSING PROGRAM(2400) <br /> [3Ilotel/Motel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Housing(2700) Use Employee IfousinelLabor Camp Applicaeion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RIVQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> ❑Out of Se <br /> Number of Pools/Spas at Facility 11 Pool 11 Spa n�ce Poo]/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ 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 /> 11 Landfill 11 Transfer Station 11 Ag/Cannery M'aste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility El CIA Site <br /> El Refuse Vehicles—Number of Units 11Dumpsters>20 cu yd—Number of Units ❑ FarnvTauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care ❑ Acute Care 11 Skilled Nursing 11 Large Generator 11 Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---E] 2- 10----❑ 11 -60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) UsePffSEIID 46-02-003 Blue Applicaeion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON _ Day Ph Night Ph _ <br /> PROGRANt ELENIENT Y & - FEE 1:1 SurchargeFEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID _ to ❑ Food Handler <br /> ❑ Check# AMOUNT I'MI) Date INVOICE# <br /> El Cash_ 1�EVIEWEDBY ACCOUNTING OFFICE �� Date �w <br /> 1 u:- <br />