COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENTIRONMENTAL HEALTH DIVISION MASTERFII,E RECORD INFORMATION FORM EH 00 69 ❑New GH Program at Existing Facility ❑Ncw EW Pro ram and New Facility Ft ^:i".Y..Sra�:a• t tccord_ID .1 �rYf v•• �1 r ''i.•'jf' •1' �a Pro Kra, Facility Address 51 D (Please Check the appropriate description and specify jjZ nu 1ber of units and ncrlincnt inform•rlion.) 14 FOOD PROGRAM(1600) ❑ Restaurant: Scaling Capacity Square Poota , 4 q &o Food I1andlcrs Course c ui c : YKs❑ No❑ ❑ Commissary ❑ Dry storage only ❑'with food Preparation P ❑Vending Maclrincs—Number of Units ❑ Rct,'hll Markct----Squarc footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goals Only ❑ Mobile hood Vchicic----Makc Vehicle Type .. Registration 9 Color License 11 Sticker Il 13 Mobile Food Prep Unit--Makc Vehicle Type Color ' Registration If License 0 Sticker 11 l] T muporary Food Facility-----Dates of operation from ' to ❑Special Event - Dates of operation ` from ❑ Ice Plant to ❑ Producc Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade I3 Dairy ❑ Milk Dispenser---Number of Containers in Multi-Wcad Unit CUP A ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ hazardous Waste Generator-----------------------Tons Generated Pcr Ycar - Ttcred Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Pcrinit-By-Rule I•Iouschold Hazardous Waste ❑ ABOVEGROUND STORA(x,TANK FACILITY(AST)(2390)----Numbcr of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Usc SUST,4 and/!forms HOUSING PROGRAM(2400) ❑ I•[otel/Motel-------Number of Units ❑Jail or Exempt Institution Number of Units Iaupinyce Iloushng(2700)Use Era'[110mc fdory lar/_nhnr C'a,..a w....Uirar...t.d•'orrrn SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 1 ❑ Environmental ASSCSsnrrenrt ❑ UST-CACP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup S(tc ❑ UIC ❑ Abandoned HW Site 1:113Site non-NPL/SEP Cleanup Site. RWQCB Cleanup Site ❑ Water Quality Iicmcdiallon site i RECREATIONAL HEALTH PROGRAM(3600)' ' Number of Pools/Spas.at Facility ❑ fool ❑Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Itenncl TATTOO 'Booy PIERCING PERMANENT COSMETIC PROGRAM(4100) ; ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permrancut Cosmrcties(4122) LIQUID WASTE PROGRAM(4200) j ❑ Pumper Vchicic--Registration# License IE Capacity 13 Pum crYard ' Vehicle N Package Treatment Plant ❑ Chemical Tolicts-------Numbcr of Units SOLID WASTE PROGRAM(4400) _ ❑ Landfill ❑Tramfcr,Station ❑Ag/Cannery Waste Site. ❑ Waste Tire Facility ❑ Compost Facility ❑ udge/Ash Site. 1 Y ❑ Process/Reeycle Facility CIA Landfill Site ❑ Refuse Vehicles--Numbcr of Units ❑ Dumpslcrs>20 cu yd—Number of Units , MEDICAL WASTE PROGRAM(4500) arntJltanch Cleanup Site ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator . ❑Small Generator ❑ Limited Ilauler ❑ Trausfer Station ❑ Veterinary Clinic E3 Common Storage.Facility....13 2- lo'---.--❑ 11 60------❑ PUBLIC WATER SYSTEM PROGRAM(46 >GO generators 00)Use1'_W�4_•ld0176911frrcAnnlrcafiorrFornr EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT'PERSON Day Ph p � • � ,46 " fF./ ?!rl4Mt1 hh/P1t0cm' 'E•L,'E^MENT r 1��1,�t�1,'li/r IY�,,1• '1 J•, :1 ❑Surcha / y' 1fV5PGCTplt/1 p• s.F;.+ ' r > x. r r arge I� � .!.• ❑ Othcr FL''1'i' PCItMITVALI 1O ! ------------- ❑ ❑i/C.hcek N AMOUN i'PAID` }� r: Food Ilartdlct' • 1 Vasil' 7 w '. 4 at 1 INVOicr.# RUVILIWC•60Y`' . r a7tt,�ACCOUNTINGC�pPtCli^:. - {' ,i.•. t'. :Dale Cil W69 PINK FORM.doc w