Laserfiche WebLink
New EH Pro ram at Existin Facilit New EH Pro ram and New Facility <br />Facility ID rADO.,,7 Program Record ID Pk)S-1-kg3D, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address>r -32 0 <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />.9/CZ-eiN v'cv- -- <br />DAIRY PROGRAM (2000) <br />O Special Event---Dates of operation from <br />Grade A Dairy <br />CUPA <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0CF0 0A0B <br />A) atxor(x_ <br />and specify size, number of units and pertinent information.) <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />Color <br />Sticker # <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <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 CI 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 />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 <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />1.r <br />48-02-034 <br />PROGRAM ELEMENT ( (0 .i ( FEE 2-72- <br />INSPECTOR # 1 si 2 PERMIT VALID 11(23 <br />1/23/13 <br />CI Check #I <br />Ni7c),c eagaREVIEWED BY ACCOUNTING OFFICE (1/1771 de <br /> AMOUNT PAID 42. Date <br />tK-- to C"3' <br />s-1-,---- <br />e0r1P4' 142%24i30 <br />MASTERFILE REC RD INFORMATION PINK <br />Date / / 2.3 <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />CONTACT PERS <br />EMERGENCY/ NQTIFICATION FOR THIS FrITY AND/OR PROGRAM SAN jo A <br />Day P eci (5(;)- Night Ph ENVi41QUI Cr) <br />0 Other FEE " EPARP47-A,,i41- ,,,„EAir <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />El Dumpsters > 20 cu yd vi of Units) <br />1:1 Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Rpc4 Cleanup Site <br />0 Small Generator <br />0 11 - 60 <br />CI Food Handler <br />INVOICE # 3'Q z'(-'g <br />YME•p",,. <br />digGelvl Y <br />> 60 genera <br />OV 2 7 2023