SU0008735 SSCRPT - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY r"VIRONMENTAL HEALTH DEPAR"LENT MASTERFIi_E RECORD INFORMATION FORM ❑New FHP ram at Existin FaciFl ❑New EH P m and New Facllit Facili ID Program Record iD MP Facility Address (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Commissary © Dry storage only ❑ with Food Preparation ©Vending Machines Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only D Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food f=acility--Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to 13 Produce Stand DAIRY PROGRAM (2000) E ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator Tons Generated Per Year ❑ RecyclelExempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility D Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Peffnit-By-Rule Household Hazardous Waste ,ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms -5- HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Housiny/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) f ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-----Maximum number of binds ❑ Kennel TATTOO-BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) D Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicieRegistrabon# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landoll ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire f=acility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 0 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Farm EMERGENCY NOTIFICATION FOR THIS FACILITY AND/oR PROGRAM CONTACT PERSON Day Ph Night Ph FONSPECTORVZ: OGRAM ELEMENT 2 0 FEE 13 Surcharge FEE ❑ Other FEE PERMIT VALID t0 © f=ood Handler 13 Check# AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15107