Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH prouam at Existing Facility ❑New EH Program and New Facility <br /> Facility ID 0 Q I LLk(o Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and fy EIZ number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑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# 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-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> I RDOUS WASTE PROGRAM(2200)" 1 <br /> Iazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> CRT Offsite Handlers(221 B) Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facilityn r y uthonzed ❑ Conditionally Exempt(CE) <br /> y_ a rxed mt ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Num bcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units IJ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housinr/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IfW Site ❑non-NPI&EP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility- ❑P901 ❑ 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 /> 11 Pumper Yard . ❑Package Treatment Plant. ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/CauneryWaste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/RecycleFacility ❑ CIALandfrllSite <br /> ❑Refuse Vehicles—Number of Unitr ❑Dumpsters>20 cuyd—Number of Units ❑Farm/Ranch 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--O 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIES EHD 66-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON ` Day Ph Night Ph <br /> PROGRAM ELENIENT -.;-,2..3Z FEE ILZS• J ❑ Surch rge FEE [IOther FEE <br /> INSPECTOR# 74'70 PERMrT VALID . 1 to I'L 3 ❑ Food Handler <br /> El Check 9 AMOUNT PAID Date 3 g INVOICE (5- <br /> ❑ Cash REviEwED BY Al 'ALatpeACCOUNTING GFFICE Date 0 <br />