Laserfiche WebLink
0- <br /> SAN JOAQUIN COUNTY ENVIRONM.ENTAL HEALTH DEPAIiT1NE,NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility KNew EH Program and New Facility <br /> Facility H) `7 C,L ; Pro ram Record ID <br /> Facility Address �.a•1` N• �l.�i� WwA 'Sio Eton 5aO S <br /> (Please Check the appropriate description and specify s•ize.,numb r of units and pertinent iaformation.) <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 ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑IiIobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Eveut —Dates of operation from to ❑ 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 /> HAZARDOUS WASTE PROGRAM(2200) q <br /> ❑ Hazardous Waste Generator.— Tons Generated Per Year ❑ 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 /> ❑Pcrrnit-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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ RoteUMotel Number of Units .❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee 1Yausinzlzbor Camp Applicaeion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HIV Cleanup Site. ❑NPLISEP Cleanup Site ❑U1C Site <br /> ❑ Abandoned I1w 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 /> ❑ 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 /> ❑ Laudfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> J9 waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site <br /> Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) ENVIRONMENTAL HEALTH <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator DEPARTMENT NO LONGER <br /> 11 Transfer Station ❑ Veterinary Clinic 11 Common Storage Facility--112 <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pll'SFFID46-02-003 Blac Application Foi INSPECTS WASTE TIRE <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND(O FACILITIES. It is a State run <br /> CONTACT PERSON Day Ph program effective 7/1/2017. <br /> PROGRAM ELEMENT ,`1 1 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 210),L PFRMITVALID to ❑ Food Handler <br /> ❑ Check# A-MOUNT PAID Date // INVOKE# <br /> ❑ Cash REVIEWED BY Q)E 4 ACCOUNTING OFFICE 'l Date <br />