Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />I Facility ID <br /> <br />ONew EH Pro ram al Existir radii ONew EH Program and NewCan <br />Facility Address / <br />(Please check the appropriate description and specify ELM number of unite and pertinent information.) <br />FOOD PROGRAM (1600) <br />pr Restaurant Seating Capacity 2'2 <br />0 Commissary 0 Dry storage only <br />0 Retail Market—Square footage <br />0 Mobile Food Vehicle --Make <br /> <br />Registration X <br />0 Mobile Food Prep Unit— Make <br /> <br />Registration # <br />0 Temporary Food Facility --Dates of operation from <br />0 Special Event--Dates of operation from <br />AIRY PROGRAM 120001 <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals. <br />o CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 1 Facility <br />0 Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />0 Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PER (2231) 0 PER HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel —Number of Units 0 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application FOM1 <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTRoL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local NW Cleanup Site 0 NPUSEP Cleanup Site UIC Site <br />Abandoned NW Site 0 non-NPL/SEP Cleanup Site 0 RWC)C13 Cleanup Site 0 Wats/ ftigrLiAbin ration Site <br />0 Out of Service Pool/Spikr..M a ral Bathh2g. Area <br />TiOrt <br />elei '1°3 <br />uto, <br />0 Body Art Facility-SONAlArE0), <br />0 Body Art-TempliSgtiVO Eligiy (4131) <br />AE10-1° • <br /> Capacity Vehicle # <br />0 Chemical Toilets —Number of Units <br />0 AgICannery Waste Site <br /> <br />0 Sludge/Ash Site <br />0 Process/Recycle Facility <br />0 CIA Landfill Site <br />O Oumpsters > 20 cu yd lot u,n) <br />0 Farm/Ranch Cleanup Site <br />CONTACT PERSON I fmsz <br />PROGRAM ELEM MP FEE <br />INsPECTort X PERMIT VALID <br />0 Surchaqge F§E 0 Other FEE <br />to 1115// Food Handl <br />0 Check AMOUNT PAID d° Date <br />1123/13 <br />74 Program Record ID ? $3 <br />Square Footage I, tr-0 <br />with Food Preparation <br />0 w/Meat Market only <br />Food Handlers Course rewired: Yes X No 0 <br />OVendIng Machines Number of lines <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License I Sticker X <br /> <br />Vehicle Type Color <br /> <br />License N Sticker <br /> to 0 Ice Plant 0 Produce Stand <br /> to OCF00A0B <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm—Maximum number of birds <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicieRegistration License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM. (4400) <br />0 Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />0 Refuse Vehicles (lot umb, <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 '60 generators <br />PUBLIC WATER_SYSTEM PROGRAM (4600) Use PWS EHD 15-02-003 Blue Application Form <br />MERGENCY NOTIFICATION FOR THIS FACILITY 0/OR PROGRAM <br />Day Ph Night Ph sr, r \_ <br />Cash <br />iteCE# <br />REVIEWED BY ACCOUNTING OFFICE ate 22-/ 1," 2,-27 <br />41 q n21 2- 6 /21, 7 <br />.02434 ERFILE RD ISPORE IO PINK