Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION PPRM <br />11 New EH Pro ram at Existing Facili ew EH Pro ram and New Facilit <br />Facility ID OO Program Record ID 7902_ <br />Facility Address (Ai.Yh.o,(I 1 2q% <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ w/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 ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USIA 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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ WatacXkLality fteliation Site <br />RECREATIONAL HEALTH PROGRAM (3600) �P''AH��TTee1I��YYII��CC��IIYYCC rr11�� <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa RIiS4�latUtrfQhing Area <br />VECTOR CONTROL PROGRAM (4000) <br />1:1--- 4d �1 I��22 <br />Poultry Farm --Maximum number of birds <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4 100) SAN JOAQUIN COUNTY <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Faci�f3� 20) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp obi a acility (4131) <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 />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of units) ❑ Dumpsters> 20 cu yd (#of units) ❑ Farm/Ranch Cleanup Site <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 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />PROGRAM ELEMENT <br />INSPECTOR #, /�I LJd'I PERMIT VALID <br />11Check# V 15-)4 AMOUNT PAID <br />I t <br />L3 Cash REVIEWED BY 1 %1 I,A f r'I <br />_ Day P <br />❑ SI <br />'Lo ;I <br />Date <br />ACCOUNTING OFFICE <br />1/23/13 <br />Night Ph 5' -CA - <br />0 <br />C <br />❑ Other FEE <br />❑ Food Handler <br />Z INVOICE # <br />Date / <br />