Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 1211\l'ew EH Pro.gram and New Facility <br />Facility ID 72:2 gg-0 Program Record ID Pkostrvb _ <br />Facility Address '.-1-1 -2--- C.-1'41 NI e(z. PNX/ C-- , -•f-c.•Dc-K-:--r-br-i c/N. cis- 2-c71-3--- <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 CI No 42( <br />0 Commissary Et' Dry storage only CI with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Li Mobile Food Prep Unit-- Make Vehicle Type C A F. T Color <br />Registration # License # Sticker # `1 .4- / Co <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (41201, <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event MobSEPaclilliy (0444 ) <br />LIQUID WASTE PROGRAM (4200) <br />stiEALTH <br />DEPARTMENT <br />JQAQDUEIN COUNTY <br />CI Pumper VehicleRegistration # License # Capacity v <br />El Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Unit <br />CI Landfill 0 Transfer Station Ag/Cannery Waste Site <br />tc11412.0h1MaLTAL <br />SOLID WASTE PROGRAM (4400) <br />CI Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (ti of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 El >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON JE" M CZ EST,i.P_.> 1-1-0 Day Ph Si 0 -4:_70c1--cDtight Ph <br />PROGRAM ELEMENT 14 3 FEE P 0 7 0 0 Surch4rge F E 0 Other FEE <br />INSPECTOR # PERMIT VALID i i 2-v 2 to 12-I 3 1 -1,2-3 0 Food Handler <br />Check # AMOUNT PAID 11 /0 -7-- Date INvoicE# <br />Cash REVIEWED BY ACCOUNTING OFFICE Date <br />KemPAYMENT <br />RECEIVED <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />48-02-034 <br />1/23/13 <br />MASTERFILE RECORD NFORMATION PINK