Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I' <br />MASTERFILE RECORD INFORMATION FORM J <br />❑ New EH Proaram at Existina Facility h{ New EH Proaram and New Facility <br />Facility ID X00 ;15 19 Proaram Record ID 2r7 � 0�211 <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />��IS <br />71Restaurant: Seating Capacity Square Footage Food Handlers Course <br />required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/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 ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Fagility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year %� y) <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PER 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 ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use EmploVee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW 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 ❑Pool <br />Out f Service Pool/S❑Natural BathinArea <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />TATTOO, BODY PIERCING, <br />❑ Spa ❑opa g <br />❑ Kennel <br />PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Single Use (4120) <br />El Body Art Facility -Sterilization (4121) 11 Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle Registration# <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />1:1 Landfill 1:1 Trans Station <br />Capacity Vehicle # <br />[I Pumper Yard <br />❑ Chemical Toilets ----Number of Units <br />11 Ag/Cannery <br />Li Waste Tire Facility ❑ Compost Facility <br />El Refuse Vehicles (#of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Waste Site <br />❑ Process/Recycle Facility <br />❑ Dumpsters > 20 cu yd (# of Units) <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />El Primary Care ❑Acute Care ❑ Skill ed Nursing El Large Generator ❑Small Generator El Limited Hauler <br />El Transfer Station El Veterinary Clinic ❑Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application <br />Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM EL <br />I� <br />❑ Check # <br />FEE p Surcharge FEE El Other FE <br />NSPECTOR # E <br />_ PERMIT VALID t0 <br />AMOUNT PAID Date <br />❑ Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />ACCOUNTING OFFICE <br />El Food Handler <br />_ <br />INVOICE # �J3?J71 <br />Date 1 J C�'j�_ <br />MASTERFILE RECORD <br />INFORMATION PINK <br />