Laserfiche WebLink
0 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Program and New Facility <br /> Facilif ID D( ' � 7 Pro ram Record ID 3��S <br /> facility Address ' 0 • �oG�n G- 1J�- <br /> (Please Check the appropriate description and specify size.number of units and Cerfinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only L1 with Food Preparation ❑Vendiag 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 /> ❑ 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 ❑Milk Dispenser Number of Containers in Multi-Bead Unit <br /> ~ CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' 1 <br /> ❑hazardous Waste Generator.. - Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ AppIianee Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> Cl 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.9 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Iiotentotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Enrployee I-fousirtKobor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local IIW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned I11V Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing 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/Cannery Waste Site Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process(Recycle FacilityUAICIA•Landfill Site <br /> ❑ Refuse Vehicles—Number of Units _ ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑SU-led•Nurs"Ing ❑ Large Generator ❑ Smal[Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--D 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER_ SYSTEM PROGRAM(4600)UscPII'SEKD 46-02-043 Blue Application Form <br /> EMERGENCY 140TIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR,0iELEh1ENT u"13�` FEE ❑Surcharge FEE ❑ Other FEE — <br /> INSPECTOR#���-� PERMITVALID__—�— to ❑ Food Handier_ <br /> ❑ Check g An OUNT PUD Date 11,VOICE <br /> Cash LU','IEwF.DBY ACCOL7NTING`'}FF11CE _ Date --- -__ <br />