Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH P ram at Existin FaciF' ONew EH P ram and New Facility <br /> Facility ID 5W f P rare Record ID <br /> Facility Address 2CdboS kpk-,�P`-vf-A X-0 <br /> (Please check the appropriate description and specify size,number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> Cd Restaurant: Seating Capacity Square Footage Food Handlers Course reaulred: Yes❑ No ❑ <br /> ❑ Commissary 0 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 #o ❑ Produce Stand <br /> DAIRY PROGRAM 120001 <br /> ❑Grade A Dairy ❑ Grade 8 Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> C,1 PA ❑ State Facility Surcharge(2399) <br /> HAZ,,MDOUS WASTE PROGRAM(2200) r <br /> Hazardous Waste Generator.----Tons Generated Per Year J ❑ Recyclell:xempt System(2299) <br /> ❑ CRT Offsite Handlers(221$) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Perrnitting Facility ❑ Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule f=ixed 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 Institution—Number of Units <br /> Employee Housing(2700)Use Employee HousiniV ahor Camp Application Form <br /> SITE MITIGATION(2900) UNDER R UND INJECTION C NTR L(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP 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 PoolfSpa © Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Faun-------Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCINS PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> UQU-1D-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 t#of Units) - ❑ Dumpsters>20 cu yd(1f of units) ❑ FarmlRanch Cleanup Site <br /> MEDICAL WAIS,TE 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 MUM PROGRAM(46030)Use frl+VS EHD 46-02-003 Blue ApplicaiSlon Fimn <br /> EirERG1=NCY NOTIFICATION FOR THIS FACILITY Ari OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> t PROGRAM ELEMENT 2-7-20 FEE '-LI-2>-D 0 ❑ Bunch a FEE ❑ Other FEE <br /> INSPECTOR# U-10__ PERMIT VALID to ❑ Food Handier <br /> ❑Check# AMOUNT PAID Data JNVOICE# 1 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> iP[.eAl/C eA u. gecl k"W11 WA 2 3 <br /> 4"2-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15107 <br />