Laserfiche WebLink
o Surchap F <br />to 3OE <br />Date I <br /> <br />iry <br />INSPECTOR # <br />Check # <br />Cash <br />48-02-034 <br />1/23/13 <br />PROGRAM ELEMENT IV 13 FEE <br />JMAGI PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />17 2-2-5-8-'163 <br />ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAY MP Ai <br />MASTERFILE RECORD INFORMATION FORM RECEIVED <br />New EH Program at Existing Facility <br />Facility ID p-400.27 ?5- <br />Facility Address 0 3 s-c-- <br />CINew EH Program and New Facility NO v u 201 <br />ram Record ID a os-41-E <br />SAN JOAQUIN COUNTY <br />I C,4 <br />Pro <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />vt/X H <br />ENVIRONMENTAL <br />LTH DEPARTMENT <br />,FOOD PROGRAM (1600) <br />715-Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />' 0 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 <br />Registration # <br />Mobile Food Prep Unit-- Make <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 <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 />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 />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 0 UIC Site <br />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 <br /> <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TAr1-00, 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 # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station LI Ag/Cannery Waste Site <br /> <br />O Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility LI Process/Recycle Facility <br /> O CIA Landfill Site <br />Refuse Vehicles (if of Units) 0 Dumpsters > 20 Cu yd (if of Units) <br /> O Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 > 60 generators <br />Registration # Sticker # <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />Color <br />Sticker # <br />Color <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCy NOTIFICATION FOR THIS FAJCILITY ND/OR PROGRAM <br />CONTACT PERSON 6k ,4 4A t lei Day h 7-‘0 Night Ph <br />Other FEE <br />Food Handler <br />INVOICE # 8i10 2,r) <br />Date /1 3 .23 <br />MASTERFILE REC RD I FORMATION PINK