Laserfiche WebLink
1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Pro•ram at Existin. Facilit <br /> 0New EH Program and New Facility <br />Facilit ID q-CID <br /> <br />Pro • ram Record ID <br />Facility Address kcib <br />(Please check the appropriate description and specify size, number of its and pertinent infor ation.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEsA, No 0 <br />Commissary 0 Dry storage only <br /> 0 <br />with Food Preparation OVending Machines Number of Units <br />Retail Market---Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to El CFO 0A0B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CuPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200)------>- Tons Generated Per Year <br />Tiered Permitting Facility ------> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel -----Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm-------Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (0 of unto) 0 Dumpsters > 20 cu yd (tt of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON \--6a. ‘_ A ir Day Ph 9A -R:32- 1Z22,Night Ph <br />PROGRAM ELEMENT k loatb FEE Ak:Z,_- 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # 1--• ' r\1r\ckr PERMIT VALI r t (1) - tCt • 22.. to I 0 Food Handler <br />Check // AMOUNT PAI • 11° i %, C5-0 Date (...) AV iNvoicE# <br />Cash REVIEWED BY ACCOUNTING OFFICE a i Date 2Z-- <br />48-02-034 <br />1/23/13 <br />0,S748-02.6- <br />-Ti <br /> 9S33-(c) <br />Mobile Food Prep Unit- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event--Dates of operation from <br />2 <br />MASTERFILE RECORD INFORMATION PINK <br />is Is( -2a3