Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION F M MH 00 69 <br /> ❑New CH Program at Existint Facility cW EH Pro ram and New Facility <br /> NA.:Pr .•a;V r,a-��.crl.� .•. .,`r'�:f;:',, i a'.. <br /> II o rani Record ID ` jZZ( •- <br /> �(Plcasc <br /> facility Address 7 ,rO /�t� .s �Check the appropriale description and specify sire I12mbcr of units and per ment information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Stating Capacity Square Footage Food handlers Course c circ : ws❑ No ❑ <br /> ❑ Conunissary ❑ Dry storage only O'with Food Preparation ❑Vcuding Macliincs—Number of Units <br /> ❑ Rctpll Market----Squarc footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vchicic Typc Color <br /> Registration q Liccnsc lI Slicker 11 <br /> ❑ Mobile Food Prep Uuit-1Makc Vchicic Type Color <br /> RegisUation 1 <br /> 1 Liccnsc H Sticker H <br /> ❑ Temporary hoed facility-----Dates o operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation - rom to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispcuser---Number of Containers in Multi-licad Unit <br /> CUPA ❑ State Facility Surcharge(23 9) <br /> IIA DOUS WASTE PIkOGRA (2200) <br /> klazardous Waste Geller ---------Tons Generated Per Year e, <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule I-Iouschold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)---Number of AST <br /> UNDERGROUND STORAGE TA K(UST)PROGRAM(2300)Use 51ST A and!l fern <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/Motcl-------Numbcr of Units ❑ Jail or Excmpt Inslllution Numbcr or Units <br /> Empluycc 119u3ing(2700) Use Ltimlovec 11�ltsinrlLqborCamm dijolicadan!'orm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Asscssnicut ❑ U T-CIDP Site El Local 11W Cleanup Sile ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ n 1-NPL/SCP Clcauup Site ❑ RWQCB Cleanup Site <br /> ❑ Water Quality Rcntcdiallon Site <br /> RECREATIONAL HEALTH PROGRA (3600)' <br /> Numbcr of Pools/Spas.at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000 <br /> ❑ Poultry Farm Maximum number of birds ❑ 1(cn11cl <br /> TATTOO BODY PIERCING PERMANENT COSMETIC P OGRAM(4100) <br /> ❑ Tattoolug(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) i <br /> ❑ Pumper Vchicic--Registration 11 Liccnsc 11• Capacity • Vchicic 9 <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Tollcts------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer"Station. ❑Ag/Cannery Waste Site ❑SludgdAsh Site <br /> 11Waste Tire Facility ❑ Compost 'acility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Numbcr of Units ❑ Dumpsters>20 cu yd----Numbcr of Units ❑ Farm/Rancli Clcanup Sitc <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Trausfer Station ❑ Veterinary C11 is ❑ Common Storage Facility----❑ 2- 10•------❑ ll -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM 4600)Use PWSGI10069111rrcAnnricafiorrForin <br /> I EM G N NOTIFIC ION FOR THIs FACILITY AND/OR PROGRAM <br /> X_CONTACTPERSON 1 Day Ph�_ n�R a�_� Night Ph <br /> ^• I rl�e <br /> croltll �io$l2AittMEN <br /> 'y " :..r �Id f❑1 SAMu'rcd l�la1 rr�;rc�'S'Ir''�l Ir� <br /> r <br /> y t _ .g r�gc ❑ OthcrF�E <br /> Pugm ALID r <br /> ❑ , CI Food Handler <br /> Check NAmouNT- All '' Zy 1� ' I t Date <br /> ' r v� INVOICi;r1 <br /> .1 Cash <br /> L'1l V:G9 PINK FOItM.Joc ;ACCOUNrING dPt'ICL'` ;i <br /> Datc a3 0 <br /> , <br />