Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at <br />ID <br />Record ID <br />and New <br />Facility Address - .12 1 ttjQA-w ptjrz S-W)Wu Z n ( P g15zuL <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />eive <br />mr <br />Recr) <br />'IV 0 2 2021 <br />SAN JOAQUIN COUNTV <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />r-1 <br />Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ <br />Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ <br />Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />❑ CIA Landfill Site <br />Registration # <br />License # <br />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 ❑ <br />Produce <br />ElSpecial Event ---Dates of operation from to 1:1CFO L1A 11B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -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 <br />Stand <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA 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 HousinnlLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑UST -CAP Site 11 Local HW Cleanup Site ❑NPL/SEP Cleanup Site El <br />PERMANENT COSMETIC PROGRAM (4100) <br />Generated Per Year <br />Body <br />Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body <br />❑ <br />Tiered Permitting <br />Facility ------- > ❑ <br />CA (2232) <br />❑ CE (2233, 2234, 2235, <br />2237) <br />❑ PBR (2231) <br />❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA 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 HousinnlLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑UST -CAP Site 11 Local HW Cleanup Site ❑NPL/SEP Cleanup Site El <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO. BODY PIERCING, <br />❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br />❑ Kennel <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration# <br />PERMANENT COSMETIC PROGRAM (4100) <br />Body <br />Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body <br />Art Facility -Single Use (4 120) <br />UIC Site <br />❑ <br />Abandoned HW Site <br />❑ <br />non-NPUSEP Cleanup Site ❑ <br />RWQCB <br />Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO. BODY PIERCING, <br />❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br />❑ Kennel <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration# <br />PERMANENT COSMETIC PROGRAM (4100) <br />Body <br />Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body <br />Art Facility -Single Use (4 120) <br />❑ Body <br />Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />❑ Body <br />Art -Temp Event Mobile Facility (4131) <br />License # Capacity Vehicle # <br />El Pumper Yard <br />❑ Package Treatment Plant ❑Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM <br />(4400) <br />❑ <br />Landfill <br />El Trans Station <br />❑ <br />AglCannery Waste Site <br />❑Sludge/Ash Site <br />❑ <br />Waste Tire Facility <br />❑ Compost Facility <br />❑ <br />Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ <br />Refuse Vehicles pofUnits) <br />❑ <br />Dumpsters> 20 cu yd I# of Units) <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ <br />Primary Care ❑ <br />Acute Care ❑ Skilled <br />Nursing <br />❑ Large Generator ❑ <br />Small Generator ❑ Limited Hauler <br />❑ <br />Transfer Station ❑ <br />Veterinary Clinic <br />❑ Common <br />Storage Facility ❑ 2 -10 <br />❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON M0n0 C7(\V � \o <br />Day Ph Znu 1 �l) 0 - L112I� � Night Ph <br />PROGRAM ELEMENTy ( �I)0 FEE /151- ❑ Surch/�ar e F ❑Other FEE <br />INSPECTOR # EJ3 PERMIT�/ALID t/ t0 r Z ❑ Food Handler <br />4 .Check # AMOUNT PAID Date Z INVOICE # 36 <br />Cash REVIEWED BY ACCOUNTING OFFICE /ya Date )��S <br />