COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Record ID FaCIllty Address .PCl w ! � —' an to Sri, 139�/rfG (Please check the appropriate description and specify size, number of unit FOOD PROGRAM (1600) ❑ ❑ Restaurant: Seating Capacity. Square Footage 11 Commissary El Dry storage only El with Food Preparation ❑ Retail Market ----Square footage Elw/Meat Market only ❑ Mobile Food Vehicle—Make Vehicle Type ❑ Registration # License #_ ❑ Mobile Food Prep Unit-- Make Vehicle Type MEDICAL WASTE PROGRAM (4500) Registration # License #_ ❑ Temporary Food Facility --Dates of operation from Primary Care ❑ ❑ Special Event ---Dates of operation from to DAIRY PROGRAM (2000) d pertinent information.) PA yMZ R CF QED sq FEB 2 41012 Eti °A4uiry t HEgLV1 0 e M� rV Food Handlers Course reauired: Yes El No ❑Vending Machines Number of Units ElMultiple Departments 11Prepackaged Goods Only Color Sticker # Color Sticker # ❑ Ice Plant ElProduce Stand ❑CFO❑A❑B 11 Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility -- ---- > ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ TATTOO. BODY PIERCING, ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area El Kennel PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Pumper Yard ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) 139�/rfG SN9 ❑ Landfill L1 Trans Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 ❑ > 60 generators CONTACT (4600) Use PWS EHD 46-02.003 Blue Application Form 17i PROGRAM ELEMENT HI.2O FEE � ❑ SI INSPECTOR # 9 &3 � PERMIT VALID '1 z LZ— t0 , ❑ Check# V i 51,< AMOUNT PAID M Date ❑ Cash REVIEWED BY ACCOUNTING OFFICE 48-02-034 CoxF• 139�/rfG SN9 1!23/13 Night Ph ray ❑Other FEE Food Her INVOICE# Date 37;