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01-06-21 ; 09: 23AM; From:C nCo Foods #103 To: 12094683877 ;2098330051 # 4/ 4
<br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT n�C Ott-06
<br /> MASTERFiLE RECORD INFORMATION FORM
<br /> ❑ Now EH Program at ExistingFacility ❑New EH Pro ram and-Now Facllit �b✓ 00 6I
<br /> Facill ID t U 0 Z 2 Proora ecord ID
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<br /> iAdd
<br /> ,. Fac ,- ..... . ... ...
<br /> ress
<br /> (Please chock the appropriate description and specify size, number o units and pertinent information.)
<br /> FOOD PROGRAM(1600)
<br /> estaurant: Seating Capacity d Square Foota9e 69v Food Handlers Course required: Yes [ No
<br /> ❑ Commissary ❑ Dry storage only ❑ with Food Proparatlon ❑Vending Machines Number of Units
<br /> ❑ Retail Market---Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Gol ds Only
<br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color
<br /> Registration# License# Sticker t#
<br /> ❑ Mobile Food Prop Unit--Make Vehicle Type Color
<br /> Registration# License# Sticker#
<br /> Q Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand
<br /> ❑ Special Event...Dates of operation from to ❑ CFO ❑ A ❑ B
<br /> DAIRY PROGRAM (2000)
<br /> ❑ Grade A'Dalry ❑ Grade B Dalry ❑ Milk Dispensor-Number of Containers In Multi-Head U lit
<br /> CUPA
<br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals:
<br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility
<br /> ❑ Haiardous'Waste Generator(2200)---------->-Tons Generated Per Year
<br /> ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) 0 PBR HHVI. 2236)
<br /> ❑ Abovoground Storage Tank Facility(AST) (2600) Number of ASTs
<br /> ❑ Underground Storage"tank Program(UST)(2300) Use UST A and 8 forms
<br /> ❑ Other CUPA Program
<br /> HOUSING PROGRAM(2400)
<br /> ❑ Hotel/Motol----Number of Units ❑ Jail or Exempt Institution----Number of Units
<br /> —
<br /> Employoo Hous►ng (2700)Use Employee Houslng/La4or Camp Application Form
<br /> SITE M171.4ATlQN(2900) UN`_DROUNb INJECTION CONTRQI.(3000)
<br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site
<br /> ❑ Abandonod HW Site ❑ non-NPUSEP Cleanup Slto ❑ RWQCB Cleanup Site ❑ Water Quality Remedi tion Sito
<br /> RECREATIONAL HEALTH P_ GRAM (3600)
<br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bat Ing Area
<br /> VECTOR CONTROL PROGRAM(4000) 11
<br /> ❑ Poultry Farm-----Maximum number of birds ❑ Kennel
<br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100)
<br /> L� Body Art Practitioner Reg (4110) O Mechanical DSPS Notification (4115) ❑ Body Art FacllitySingle Use(4, 20)
<br /> ❑ Body Art Faclllty-Sterllizatlon(4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Faclllty(4131)
<br /> i
<br /> )_IQUID WASTE PRQGRAM(4200)
<br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# i
<br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units
<br /> SOLID WASTE PROGRAM(4400)
<br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site Ci Sludge/Ash Ite
<br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site
<br /> ❑ Refuse Vehicles WorUnits) ❑ Dumpsters>20 cu yd(ss ofunn.) ❑ Farm/Ranch 61eanup Site
<br /> MEDICAL WASTE;PRQGRAM_(4500)
<br /> 13 Primary Care ❑ Acute Care ❑ Skilled Nursing F-1LargeGenerator ❑ Small Generator El Llmlt d Hauler
<br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Faclllty. 0.2-10 ❑ 11 -60 ❑ >601 enerators
<br /> PUBLiC W_ A_T_ER_ SY_STEW PROGRAM (4600) Use PWS EHD 46.02-043 Blue AppllCaflon Form
<br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM
<br /> CONTACT PE=RSON Day Ph Night Ph
<br /> PROGRAM ELEMENT 6 FEE U ❑ Surcharge FEE ❑ Other FEE
<br /> IN5PF-CTOR# PERMITVALID j1q12jto ?- 3 0 Food Handler
<br /> 13Check fi v✓e b AMOUNT PAID Date Z INVOICE# J. =
<br /> L1 Cash REVIEWEO.By ACCOUNTING.OFFICE'• Data t' 1 "
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