Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at <br />Record ID <br />.,e Facility Address _6D W, GIWr Komi, J-),xG—Tq <br />3�-7to <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with? Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit— Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event --Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dalry ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200)------> -Tons Generated Per Year <br />❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Hous/nn Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site Cl Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ----Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />(4100) <br />❑ Kennel <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets —Number of Units <br />❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# 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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />i CONTACT PERSON b fl(AnVlVf) SUnanb Day Ph •bt5 N2 / Night Ph I -M' `tl * `IL 1 "1 <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# LNf\V\0\(-f�ERMITVALID X22 to ❑Food Handier <br />11 Check # AMOUNT PAID Dater INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 1�� <br />1/23/13 <br />