Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R C� <br />MASTERFILE RECORD INFORMATION FORM <br />OR F® <br />ew EH Pro ram at Existin Faclll ❑New EH Pr ram and New Faclll Sq 28 <br />FacilityID �p5 Program Record ID yFFN�/Ro �Q7% <br />Facility Address SSSS Vaflt C AO! 5w t R [%1�ci � A Tyo°pgRa°�N7y <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) rMFNT <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course regulred: YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only 13 Win Food Preparation [Wending 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 />�Jfsl7�' <br />❑ Grade A Dalry <br />❑ Gratle B Dalry ❑ Mllk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP 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 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 €mplovee Houslnp/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST•CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIc Site <br />❑ Abandoned HW Site ❑ non-NPLISEP 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 PoollSpa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds ❑ Kennel <br />BODY PIERCING, E C PROGRAM (4100) <br />K.Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility4ingle Use (4120) <br />❑ Body Art Facility-Storllization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehlcleRegistration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Agicannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Procoss/Rocycle Facility ❑ CIA Landfill Sits <br />❑ Refuse Vehicles is of units) ❑ Dumpslers > 20 cu yd Is of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Caro ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limped Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2.10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02403 Blue Anpllcadon Form <br />CONTACT <br />Day <br />Ph <br />PROGRAM ELEMENT �I1 I O FEE '� 1 S ❑ $t <br />SPECTOR <br />PERMIT VALID ZS to <br />❑ ChoU # AMOUNT PAID S 2..60 DSIe <br />[3 Cash REVIEWED BY ACCOUNTINO OFFICE <br />z3/ <br />ht Ph <br />❑ Other FEe <br />❑ Faod Har <br />INVOICE # <br />Date <br />Scanned with CarnScannt:r <br />