Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br /> <br />Facility ID rittfb, 0111 Program Record ID mo <br />EiNew EH Pro ram and New Facilit <br />50 <br />Facility Address /g3 L3/9 Y7 V GAY/1/4-- 7/7,foi, ex; 951376, <br />(Please check the appropriate description and specify size, number of units and pertinent Information) <br />FOOD PROGRAM, (1600) <br /> <br />0 Restaurant. Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market—Square footage <br />Mobile Food Vehicle -Make <br /> <br />Registration # <br />Mobile Food Prep Unit- Make <br /> <br />Registration # <br />0 Temporary Food Facility -Dates of operation from <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200)------->- Tons Generated Per Year <br />0 Tiered Permitting Facility --> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR 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 />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 NPUSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP 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 />0 Poultry Farm—Maximum number of birds 0 Kennel <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 (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />UQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOUD WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (it of Units) 0 Dumpsters > 20 cu yd (is or Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Ge <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON DkVie Day Ph 510 -9M-25W Night Ph ‘' <br />Vehicle Type <br />License # <br /> Vehicle Type Color <br />License # Sticker # <br /> to • e Plant 0 Produce Stand <br />0 Special Event—Dates of operation from to CFO 0 B <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />Food Handlers Course required: YES E( No <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Capacity Vehicle # <br />-60 0 > 60 generators <br />CI Chemical Toilets —Number of Units PAYMENT <br />RECEIVED <br />0 Sludge/Ash Site • 1 - 2023 0 CIA Lande11wite 1 <br />0 Farm/Ranch Clmagtitir, ;;AN • <br />INVIRONMF.NTAL <br />HEALTH DEPART MINI <br />nerator u Limited Hauler <br />PROGRAM ELEMENT 1608 FEE 186 <br />INSPECTOR # 4589 PERMIT VALID ' <br />0 Check /I V 1 A AMOUNT PAID <br />0 Cash REVIEWED BY <br />43-02-034 <br />1/23/13 <br />0 Surcharge FEE 0 Other FEE <br />to tO 3 zy 0 Food Handler <br />Date rOA1151VOICE # t q1 <br />ACCOUNTING OFFICE OFFICE <br />g- 6 3 _3 Lo/2-3 <br />Date 101 / 2„ <br />STERFILE RE ORD INFORMATION PINK