Laserfiche WebLink
Program Record ID Facility ID <br />- 0 New EH Program at Existing Facility <br />.D02.DCDD <br />ONew EH Program and New Facility <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # 1\d/ 1-19,50r7- <br />Color tAJI-ti L." <br />Sticker # Iki tryq sok 9- <br />to 0 Ice Plant 0 Produce Stand <br />0 CFO 0 A 0 B <br />MASTERFILE RECORD INFORMATION PINK <br />PR 0 9-1 ii.(oD <br />0 Surcharge FEE <br />2, <br />Other FEE <br />Food Handler <br />Date Iii 2_ <br />PROGRAM ELEMENT I LP 35 FEE <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />1,ct<Vtto }4 REVIEWED BY ACCOUNTING OFFICE <br />Date \ 2 SCE, 25 INVOICE # <br />48-0 -034 r <br />1/23/13 L.. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address <br />number of units and pertinent information.) (Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />g Mobile Food Prep Unit-- Make 6(4 C.. Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to <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 />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />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 />Abandoned HW Site 0 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 />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 (4120) <br />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 # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Site <br />Refuse Vehicles (# of Units) 0 Dumpsters >20 cu yd or Units) 0 FarR Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generat L.imited Pier <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -,60 4? 60 it:Orators 844 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form sys,74Q. U/N <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM lisdiCirrO/vm --uNTy <br />CONTACT PERSON Day Ph Night Ph TH DEP ENT& <br />0 Kennel <br />Capacity Vehicle #