Laserfiche WebLink
SAN J-OAQUTIN COUNTY ENVIRONAI,ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM — <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility_ <br /> FA 0000 b Pro ram Record ID ��-��� �O <br /> Facility Addre' s �,,'�L10 L\) C (ANA011d' <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers 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 Vehicle--Make Vehicle Type Color <br /> Registration it 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(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑hliik Dispeaser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS'VASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator.. Tons Generated Per Year 11 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 ❑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 E forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotenlotel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Housinzgzbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local MV Cleanup Site. ❑NPLJSEF Cleanup Site ❑UIC Site <br /> ❑ Abandoned IiW Site ❑mon-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑'Vater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pvol ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathiag Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑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 /> ❑ Landfill ❑ Transfer Station ❑Ag i Cannery'Vaste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site <br /> ❑Defuse Vehicles—Number of Units ❑Dumpsfers>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care ❑Acute Care Skilled Nursing 11Large Generator El Small Generator 13 Limited hauler <br /> 11 Transfer Station 11 Veterinary Clinic \ ❑ Common Storage Facility---❑ 2-I0 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePIVSEND 46-02-003 BlacApplicalion Form <br /> EmERGENCY NOTIFICATION FOR THIS FACILITY ANWOR PROGRAM <br /> CONTACT PERSON_ t �A FEE _ Day Ph Night Ph <br /> I'ROGILAAt ELEhTEIv'T_ "��"1 O 3 ❑ Surcha :eFEE - other FEE _ <br /> IIVSPECI.OR#—IULPIF--: IT VALID i j( to (a ❑ Food Handler_ <br /> '11Check f AIhTOUNT PAID - -- — Date INVOICE# --El Cash ILEVIEWF:li IIY Q ACCOUNTING OFFICE- Date <br />