Laserfiche WebLink
$SAN JOAQUIN COUNTI' EN' RONNIENTAL HEALTH DEPARTMENT <br /> MASTERFILE RD INFORNIATION FORAI <br /> ❑ New EH Program at Existing Facilih New EH Pro ram and New Facilit <br /> FacilityID Program Record ID L, 0-5,9q <br /> Qsa <br /> Facility Address )T�6s- A V(2— <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 It License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vchicle 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 Dalry ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facilit} Surcharge(2399) <br /> HAZARDOUS NNASTE 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 Facilit} ------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pern-lit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROI_ND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use UST A and B(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution---Number of Units <br /> Employee Housing(2-100) Use Emploree Housing/Labor 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 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(412 1) ❑ 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-----❑ 2- 10-------❑ 11 -60------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P{VS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT L+-7 L*C> FEE ❑ Surcharge FEE ❑ Other FEE <br /> I`iSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOl NT PAID Date INVOICE# <br /> Cl Cash RE\1EIXED nv AccoUNTING OFFICE L. Date ,?7 ,,5 <br /> 48-02-034 Masterfile Record Pink <br /> 11/18/03 <br />