Laserfiche WebLink
SAN JOAQUIN COUNTYE, 1RONNIENTAIL HtALTH DEPAR" 'NT <br /> MASTERFILE RECORD IN-FORIMATION FORM <br /> New EH Pro�am at Existin Facility <br /> ❑Ne%v EH Program and New Facility <br /> Facility ID F �� Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) - <br /> Square Footage Food Handlers Course required: YES❑ No ❑ <br /> El Restaurant: Seating Capacity q ❑Vending Machines--Number of Units <br /> 11 Commissary ❑ Dry storage only ❑ with Food P Preparation <br /> Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ <br /> ❑ Retail Market----Square footage ltColor <br /> El Mobile Food Vehicle-----Make Vehicle Type <br /> Licenser Sticker# <br /> Registration# Color <br /> C1 Mobile Food Prep Unit--Make Vehicle TypeLicense� Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from to ElProduce Stand <br /> F-1SpecialEvent --Dates of operation from <br /> DAIRY PROGRAM(2000) <br /> ❑ i\IilkDispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy' El Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZAI3,DOUS WASTE PROGRAM(2200) ❑ Recycle/Exempt System(2299) <br /> Hazardous Waste Generator------------Tons Generated Per Year f��`—'� ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers(221 s) ❑ Silver Only(2222) <br /> Tiered Permitting Facility------------------ <br /> [I 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) L•se UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> 11Jail or Exempt Institution---Number of Units <br /> El Hotel/ivlotel-------Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Forni <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> Cleanup Sit <br /> ❑ Environmental Assessment ❑ UST CAP SiteClean❑u Ste Local H�❑CR"QCB Cleanupleanup Site ❑SitePL/S❑ Water Quality Reme❑diiation Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP P <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> LJ Pool ❑ Spa [I out of Service PooUSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(+100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) <br /> ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> El pumper Vehicle--Registration# <br /> ElPackage Treatment Plant ❑ N <br /> Chemical Toilets-2222-- umber of Units <br /> [:1 Pumper Yard <br /> SOLID WASTE PROGRAM(4400) [1Sludge/Ash Site <br /> ❑ Landfill <br /> L1Transfer Station C1Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> El Waste Tire Facility ❑ ❑ Process/Recycle FacilityCompost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> 11 Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ 1 1 -60 2222-❑ >60 generators <br /> El Transfer Station ❑ Veterinary Clinic <br /> 11 Common Storage Facility-----02- 10------- <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> g 5�� ❑ Surcharg Fee�_ ❑ Food Handler <br /> PROGRAM ELEMENT ? FEE , \ U to <br /> INSPECTOR# PERMIT VALID INVOICE# <br /> AriOUNT PAID t,l.�� Date q <br /> ❑ Check# Date ` �7 � <br /> REVIEWED BY ACCOUNTING OFFICE <br /> ❑ Cash Masterfile Record Pink <br /> 4"2-034 <br /> 10/6/2003 <br />