Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> K New EH Program at Existing Facility ❑ New EH Program and New Facility <br /> Facility ID r,41)6: 7 Program Record ID A657�F 83 <br /> Facility Address 236( v Ngir M 0 e&(%Jdb �A Ca <br /> (Please check the appropriate description and specify size, number of units and pertinent information .) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ 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 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. UST A and B farms <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 Housing/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 /> T4 Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body AH Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121 ) ❑ Body Art Temp Event Co-ord (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 (44b0) <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 (n of Units) ❑ Dumpsters > 20 cu yd (a of Units) ❑ Farm/Ranch bleanup Site <br /> MEDICAL WASTE PROGRAM (4500) Y� <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Li <br /> ❑ Transfer Statioq, ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 1111 - 60 ❑ j <br />