Laserfiche WebLink
SAN JOAQUIN COUNTY EN' )NMENTAL HEALTH DEPARTM <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility 0New EH Program and New Facility <br />, — <br />Program Record ID <br />1—)r <br /> Facility ID i <br /> <br />Facility Address <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 0 No CI <br />CI Commissary 0 Dry storage only CI with Food Preparation El Vending Machines Number of Units <br />Retail Market----Square footage Cl w/Meat Market only 0 Multiple Departments CI Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # .7q 2-6, ZS I Sticker # q--1-1.35-- <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program CI Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />CI Hazardous Waste Generator (2200) > Tons Generated Per Year <br />CI Tiered Permitting Facility > CI CA (2232) El CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa El Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />0 Refuse Vehicles (# of Units) El Dumpsters > 20 Cu yd (# of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care CI Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI ii - 60 CI > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON <br /> <br />Day Ph Night Ph <br /> <br />PROGRAM ELEMENT FEE .;2 -5. 0 0 Surcharge FEE <br />INSPECTOR # PERMIT VALID 5 to 2_ 3 ' CI Food Handler <br />CI Check # ,_..-t AMOUNT PAID T) ---/ •06 Date 3 .5" INVOICE # <br />Z hi <br /> <br />MASTERFILE RE D If\IFORMATION PINK <br />Date <br />48-02-034 <br />tE7/7 1:1 Cash REVIEWED BY ACCOUNTING OFFICE <br />CI Other FEE <br />1/23/13