Laserfiche WebLink
Apr 05 22 02:43p Century 21 M&M & Assoc. 209-334-2550 p.3 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFiLE RECORD INFORMATION FORM <br />(P!ease check the appropriate description a.nd specify size, number of units and gertiient information.) <br />FOOD PROGRAM (1600) <br />PAYMENT <br />RECEIVED <br />AUG 15 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />NEgLTH DEPARTMENT <br />❑ Restaurant: SeatiFood Handlers Course re ufred:ng Capacity Square Footage YEs ❑ No O <br />El Commissary 11 Dry storage oily El with Food Preparation ElVending Machines Numbcr of Units <br />El Retail Market ---Square footage ClwlMeat Market only ❑ A9ultiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make- _ Vehicle Type Color _ <br />Rec,stration # License 4 Sticker # <br />❑ Mobile Food Prep Unit-- Make Venide Type ! Color <br />Reclstration # License It _ Slicker # <br />11 Temporary Food Facility --Dates of operation from :o _ El Ice Plant El Produce Stand <br />ElSpocial Event ---Dates of operation from to ❑ CFO CIAO B <br />DAIRY PROGRAM {2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Contamers in t11a Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (10.00) Number of chemicals. <br />❑ CaIARP Program El Program 1 Facility 11 Program 2 Facility El Program <br />3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232; ❑ CE (22330 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2.800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Uso UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel ------Number of Units ❑ Jail or Exempt Institution----Numbe" of Units <br />Employee Housing (2700) Use Employee HousinalLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />El Environmental Assessment ❑ UST -CAP Site El Local HW Cleanup Site ElNPLISEP Cleanup Site [3 UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCS Cleanup Site ❑ Water Quality Remediatlon Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑Pool D Spa El Out of Service PooliSpa ❑Natural Bathing <br />Area <br />VECTOR CONTROL PROGRAM (40001 <br />D Poultry Farm---•---fvlaxilnurr number of birds ❑ Kennel <br />TATTOO BODY PIERCING* ,PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110] ❑Mechanical OSPS Notification (4115) Body Art Facility -Single Use (4170) <br />❑ Body Art Facility-Sterilizatlon (4121) ❑ Body Art Temp Event Co-ord (4130) 11 Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VelticleRegistration # License # _ <br />El Purn per Yard ❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />El Landfill ❑Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />El Refuse Vehicles (s of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care ❑Acute Care El Sk111ed <br />❑ Transfer Station L3 Veterinary <br />Capacity Vehicle # <br />❑ Chemical Toilets---Nur7ber of Units _____ <br />❑ AglCaltnery Waste Site <br />❑ Sludge/Ash Site <br />❑ ProcesslRecycle Facility <br />❑ Dumpsters > 20 cu yd ;k of Units) <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cloanup Site <br />❑ Nursing [2 Large Generator ❑Small Generator ❑Limited Hauler <br />❑Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46.02.003 Slue Application Form <br />Clinic <br />CONTACT PERS <br />Jay Pi - <br />PROGRAM ELEMENT, +•� I a0 _ FEE _,Z 3 / ❑ Surclia <br />INSPECTOR # '7O � �+ _ PLItt.4i'r VP\LIIZ 8 (S ZrZ t0 <br />❑ Check 0 �— AMOUNT PAID 2D - 0U D91e <br />❑ Cash R: VI YfGO OY <br />AGGOUK TIYG OFFIG'_ <br />48.02-054 <br />rn�rs <br />Z43 <br />fJignl Fr 1�1' <br />FE ❑Other FEE <br />❑ Food Handler <br />ZZ INVOICE 9 jeo�S <br />—^ Date 8 Z2— <br />MASTERFILE RECOFfDO INFORMA11014 PINE: <br />