Laserfiche WebLink
• ( SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTII7ENT <br /> MASTERFILE RECORD'INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Program and New Facility <br /> Facilit •rD pD `13 Pro ram Record ID S <br /> Facility Address q N 7fa 53b <br /> (Please Check the appropriate description and specify size,number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES El No ❑ <br /> ElCommissary ❑ Dry storage only El with Food Preparation ❑Fending Machines—Number of Units <br /> El Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ 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 ❑ Ice Plant <br /> [I Special Event —Dates of operation from to 11 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAM(2200) d <br /> ❑Hazardous Waste Generator— Tons Generated Per Year ❑ Recycle I Exempt S)'stem(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B Loris <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee goasinjZ L bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑Local MV Cleanup Site, ElNPLISEP Cleanup Site ElUIC Site <br /> ❑ Abandoned IIAV Site ❑ non-NPLISEP Cleanup Site ❑R)VQCB Cleanup Site ❑Water Quality Remediation Site " <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11Landfill E] Transfer Station El Ag/Cannery\Vaste Site <br /> 11 Sludge/Ash Site <br /> KWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Sl illed Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2- 10 ❑ ll-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS ETTD 46-02-003 Blue Appfication Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> i <br /> PROGP_& mELEMENT_ 140_ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPEc-rop, � PEK1,11TVALID to 11 Food Handler__ <br /> CJ 6hcckf.`- ._mournP.hAin Date 11FV0ICE# <br /> El Cash ILI:VIEwED IIY Al.COUI'1TI1,OFFICE __ Date �_� <br />