Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ew EH P7ograrn and New Facility <br /> Facility ID Program Record ID/4'K0 57341go 5,fD 3`}-7 <br /> Facility Address ` �Z2D )r?20 <br /> (Please check the appropriate description and specify size, number of units an ertinent infor ion.) — <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 ry <br /> lel Hazardous Materials Business Plan (1900) Number of chemicals: L <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> t l Hazardous Waste Generator(2200)----------> Tons Generated Per Year L 1;'Am <br /> El Tiered Permitting Facility -------> El CA(2232) El CE (2233, 2234, 2235, 2237) ❑ PER(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br /> ❑ Other CU PA 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 ❑ NPL/SEP Cleanup Site ❑ UIC site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB 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 /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper VehicleRegistration# 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 pofunits) ❑ Dumpsters> 20 cu yd (#or 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 /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PR GRAM <br /> CONTACT PERSON I n� 7 ¢ j Day�Ph Zry{' �'" 06 Night Ph <br /> PROGRAM ELF;ME T,{n�"a"7'D FEE ¢�S — r7<r5�charge FEE ❑ Other FEE <br /> INSPECTOR# VDr nr rc PERMITVALID t0 ❑ Food.Handler <br /> ❑ Check# / AMOUNT PAID Date INVOICE# -140 gr'133 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 31 1 <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br />