Laserfiche WebLink
PA YmEN <br />RECEIVED <br />sAivivov o 7 2023 <br />JOAQUIN COUNTY <br />ATZN T <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Pro ram and New Facility <br />Facility ID PA-V-0 21-61 3 2, Program Record ID <br />Facility Address VNI , Mal n --`;t 2-0 PA E-91A <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 El No 0 <br />Commissary 0 Dry storage only 0 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 />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to -0 Ice Plant 0 Produce Stand <br />I=1 Special Event---Dates of operation from to E CFO aA 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 />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 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 />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El 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 0 UIC Site <br />El 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 El Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />El Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 1:1 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station El Ag/Cannery Waste Site El Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility El CIA Landfill Site <br />Refuse Vehicles (# of Units) 1:1 Dumpsters > 20 cu yd of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care El Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic El 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 13 1 t&+"" (-Ire 2-- Day Phkab t4)12 ti Night Ph <br />le t • <br />It p <br />1111 <br />PROGRAM ELEMENT CO g FEE <br />INSPECTOR # PERMIT VALI <br />El Check #c-,S?-fr AMOUNT PAID <br />El Cash <br />REVIEWED BY <br />48-02-034 <br />1/23/13 <br />171 6.6.70,5 <br />Surch rge F <br />to 712 1:1 Food Handler <br />Date NVOICE#C .O.l 6 <br />Date <br />STERFILE RECORD NFORMATIO INK <br />II i/V <br />El Other FEE <br />ACCOUNTING OFFICE