Laserfiche WebLink
Color <br />Sticker # <br />0 Ice Plant CI Produce Stand <br />CI CFO 0 A 0 B <br />to <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FIRM <br />New EH Program at Existing Facility New EH Program and New Facility <br />Facility Address C 7 -770 cAtl civ ,A st s\ c \r( <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <br />CA-fa() vv3 <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy El Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment CI UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site CI non-NPL/SEP Cleanup Site El RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles or units) El Dumpsters > 20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />DI Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator 0 Small Generator CI Limited Hauler <br />CI Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2-10 CI 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />rtv tAnc. 1 .)(14 A.)01.) etit EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERS Day Phi 2_0(1, 2. iL2)ight Ph <br />;2272-' <br />72-o 2- I NVOICE # 3 <br />Date <br />48-02-034 MASTERFILE RECORD.INF RMATION PINK <br />1/23/13 kcStk,t c.e4-vtAkT, <br />Facility ID Ma).2-7,S74 Program Record ID r P12.054g2-1.7 . <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation ElVending Machines Number of Units <br />w/Meat Market only El Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />1:1 itgatitttArea <br />:RECEIVED <br />Capa <br />Body Art Facility-Si CIP41A3 <br />Body Art-Temp EsAntAptififft~131) <br />ENVIRONMENTAL <br />city <br /> HEARiegllt1/4RTMENT <br />Sludge/Ash Site <br />CI CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />\:(0 q PROGRAM ELEMENT EE <br />INSPECTOR # PERMIT VALID <br />Check # <br /> <br /> AMOUNT PAID <br />REVIEWED BY <br />— Date iL3 <br />ACCOUNTING OFFICE <br />El Surchprge F <br />to <br />CI Other FEE <br />I=1 Food Handler <br />3( 23