Laserfiche WebLink
SAl� tiJOAQUIN COUNTY EPWONMENTAL HEALTH DEPAR-6ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility . --�►� <br /> Facility ID ®0 1,3 Pro ram Record IDFacilityAddress s:.w.�l.�- <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 ❑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 /> ❑ Special Event —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 /> COPA ❑ State.Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <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 /> ❑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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Instituti6n. Number of Units <br /> Employee Housing(2700)Use Employee Housinj/Eabor 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-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site . <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas 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 /> ❑ 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--Number of Units ❑Dumpsters>20 cu yd---Number 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-13 2-10--❑ 11-60---- ❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE a) [] Surcharge FEE 11 Other FEE <br /> INSPECTOR# J 1( PERMIT VALID -7 to to (3 Q ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 Masterfile:Record Pink <br /> i n1<nnn� <br />