Laserfiche WebLink
� I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORI\IATION FORM <br /> ❑New EH Program at Existing Facility ,KNew Ell Program and New Facility <br /> Facility ID 00't�'0—c— Pro ram Record ID 5 <br /> F acility Address f Avzf, LJL4s 1 <br /> (Please Check the appropriate description and specify size,number of units d Certinenl info(mation.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food IIandlers Course required: YES ❑ No ❑ <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\'chicle--Make Vehicle Type Color <br /> Registration# License N Sticker 0 <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration€F License 9 Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plaut <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Numbcr of Containers in Multi-Head Unit <br /> C1r^A ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) t <br /> El Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle(Eaenrpt 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) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Ptotel Numbcr of Units ❑ Jail or Exempt Institution--Numbcr of Units <br /> Employee Ilousing(2700) Use Fmployee Jfousirti Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnAroumental Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑ tiVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License ff Capacity Vehicle€€ <br /> ❑ Pumper Yard . ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Caunery Waste Site ❑ Sludge/Ash Site <br /> M�Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu.yd —Number of Units ❑ Farm/Rauch 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--EJ 2- 10--❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PffSEfID 46-02-003 BlucApPlicarion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 217-VO FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PEMllTVALID _ to ❑ Food Handler <br /> ❑ Clr_ck AMOUNT PAID Date ItwolcE it <br /> ❑ Cash R r_v1Ewr-D s9 �— ---------Accouwwai OFFICE — ate - <br />