Laserfiche WebLink
SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR ENT <br /> MASTERFrLE RECORD INFORML ATION FORM <br /> ❑-New EH Pro mat Existing Facility 5&ew EH Pro am and New Facility <br /> Facilit ID i�aoZ ProeramRecord <br /> Facility Address <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: No ❑-- — <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ts <br /> ❑ Retail Market----Square footage ❑ with Meat Market only El Multiple Departments El Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ <br /> Mobile Food VehiclestraMake Sticker# <br /> Registration# � License <br /> Vehicle Type Color <br /> ❑ Ntobile Food Prep Unit--Make License" Sticker# <br /> Registration# r <br /> to ❑ Ice Plant <br /> 13 Temporary Food Facility-----Dates of operation from ❑ produce Stand <br /> ❑ Special Event --Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> El Grade A Dairy ❑ Grade B Dairy <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) J`-� <br /> azardous Waste Generator------------Tons Generated Per Year `(%V1 El Recycle/Exempt System(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 ❑Pemtit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution—Number ofUnits <br /> 11 Hotel/Motel-------Number of Units <br /> Employee Housing(2700)Use Employee Housine/Labor Camp App!lcatian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11Environmental Assessment ❑ UST-CAP Site- ❑ Local HW Cleanup Site C1NPL/SEP Cleanup Site El UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNVQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool 11 spa <br /> ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Ca aci Vehicle# <br /> ❑ Pumper Vehicle—Registration# License#. P ty <br /> El Pumper Yard <br /> ❑ Package Treatment Plant El Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ A /Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill El Transfer Station g ❑ CIA Landfill Site <br /> El Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> El Refuse Vehicles—Number of Units [IDumpsters>20 cu yd--Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> Small Generator ❑ Limited Hauler <br /> 1:1 Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator El❑ 2-10-- ❑ 11 -60-11 >60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> El Common Storage Fact <br /> PUBLICPUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> FEE �— ❑ Surcharge FEE -f <br /> El other FEE <br /> PROGRAM ELEMENT 7/�•LO I to QEti•3-I O7- ❑ Food Handler <br /> 'S PERMIT VALID INVOICE# <br /> INSPECTOR# � � ' <br /> AMOUNT PAID— Date <br /> Check# Date <br /> ACCOUNTING OFFICE <br /> ❑ Cash REVIEWED BY -rtM rs+f� 5 1 • Mastehle Record Pink <br /> 48-02-034 <br /> 40/6/2001 D'F'Cl •v _ t /Ct'1 <br /> 5kaa <br />