Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID <br />New EH Program and New Facility <br />Program Record ID <br />Facility Address 12)0 S <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br /> <br />Registration # <br />Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />and specify size, number of units and pertinent information.) <br />Square Footage Food Handlers Course required: YES 0 No 0 <br />0 with Food Preparation OVending Machines Number of Units <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />CoAt-eo(no( SIDett-NQ C )2-0-70 <br /> Vehicle Type <br />License # <br />Vehicle Type <br />License # Sticker # <br />Color <br />Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <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 El 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 El UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP 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 <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El 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 VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (4 of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 1:t. <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility El 2 - 10 0 11 - 60 I/Ear <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FAC LITY ND/OR PROGRAM <br />0 Kennel <br /> License # <br />0 Package Treatment Plant <br />El Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br /> Capacity Vehicle # <br />El Chemical Toilets ----Number of Units <br />El <br />prAYAfeivr <br />Sludge/M/Ifee&m, . <br />CIA Landfill Site 4=iveo <br />Farm/Raktlyflr,up Site <br />2023 <br />OiJu,ier <br />h? <br />CONTACT PERSON ,-/oSe /46 Day P 773/ Night Ph 2cy 5. 3 / --e1V, 5 7 <br />PROGRAM ELEMENTV97 FEE <br />INSPECTOR # CAS1, PERMIT VALID <br />1/23/13 <br />091#: 15 3 380 <br />visw 4- 48-0 -034 <br />il112-ieck # <br />REVIEWED BY <br />AMOUNT PAID <br /> to <br />c <br />12- 3/_ 1 2,3 0 Food Handler <br />-4-, Date 2 23-12-5 INVOICE # <br />ACCOUNTING OFFICE ejhri.A7 (19 — Date <br />0 Surch rge F(E 0 Other FEE <br />ovi -to- 2A2,4- TnE R_ I(371 T7 PINK, , <br />c. <br />I <br />GA phyu2. pa,,e' L L,13. auD