Laserfiche WebLink
4s^0S <br />to <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR HHW (2236) <br />a <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility <br /> License # <br /> Package Treatment Plant <br />_________] <br /> New EH Program at Existing Facility J^New EH Program and New Facility <br />I Facility ID Program Record ID <br />Facility Address /zc/^/ <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br /> Commissary 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 /> Special Event-Dates of operation from <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation Vending Machines Number of Units __ <br /> O w/Meat Market only Multiple Departments Prepackaged Goods Only <br />__________________ Vehicle Type Color <br /> License# Sticker# <br />________________ Vehicle Type Color <br /> License# Sticker# <br /> Ice Plant Produce Stand <br /> CFO A B <br />CONTACT PERSON- . — = <br /> Capacity ____ v^a 1 2024 <br /> Chemical Toilets -Number of WfjewwrcouNTY <br />ENVIRONMENTAL <br /> siW^W^^tment <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />Emergency Notification for this FACILITY and/or PROGRAM <br />2 - ' Day Ph^2--Night Ph —It/ <br /> Surcharge F£e _ Other FEE <br />to I 3*/ ( I / □ Food Handler <br />Invoice # <br />/r/ Date <br />i MASTERFILE RECdRD ll/FORMATiON PINK <br />CD2T 'Z- <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) Number of chemicals: <br /> CalARP Program Program 1 Facility Program 2 Facility <br /> Hazardous Waste Generator (2200)------------>-Tons Generated Per Year <br /> Tiered Permitting Facility--------> CA (2232) CE (2233, 2234, 2235, 2237) PBR (2231) <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 Jail or Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <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) □ Mechanical DSPS Notification (4115) □ Body Art Facility-SinglJ^/^(442$) * I <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp Event $ilJtti(e>Ej(^$y^131) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper Vehicle Registration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (« of Units) <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator Limited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 Oil -60 □>60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Program Element / ? 3 Fee ("7^1 ' ’ <br />Inspector #C4fLU6lL^v Permit Valid <br />□ Check # V 1-5 M Amount Paid ' 0316 <br />□ Cash_______Reviewed by I ^^Accounting Office