Laserfiche WebLink
RF yMF <br /> C�jVF T <br /> SqN :/qN-3' ?03 <br /> o <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT F �04QU <br /> MASTERFILE RECORD INFORMATION FORM HEq�T�IRp�INOO <br /> ❑New EH Pr ram at ExistingFacilityNew EH Pr ram and New FacilityH�Epq coo y <br /> Facili ID �� Pro ram Record ID TME/vT <br /> Facility Address ( ` I CA S 3 6.1 <br /> (Please check the appropriate description and specify size,nu ber of units and perti ent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs K No❑ <br /> ❑Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑w/Meat Market only ❑Multiple Departments❑Prepackaged Goods Only <br /> ❑Mobile Food Vehicle–Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit–Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑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 Dairy ❑Grade B Dairy ❑Milk Dispenser-Number of Containers in Mutti-Head Unit_ <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑CaIARP Program ❑ Program 1 Facility ❑Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200) >-Tons Generated Per Year <br /> ❑Tiered Permitting Facility—> ❑CA(2232) ❑CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ 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 /> ❑Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housino/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site ❑NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <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 Cord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑ Process/Recycle Facility ❑CIA Landfill Site <br /> ❑Refuse Vehicles I#of Units) ❑ Dumpsters>20 cu yd(#of urns) ❑ Fann/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 /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph QC4-4& a5-_cZNight Ph L am_ <br /> PROGRAM ELEMENT ( C FEE ❑Surcha e F E _ ❑ Other FEE <br /> INSPECTOR# - PERMIT VALID 3 to L 3 I Z ❑ Food Handler <br /> ❑Check# AMOUNT PAID Date INVOICE# 2 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 <br /> 123/13 MASTERFILE !FORMATION PBW <br />