Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ow EH Pro am at Existing Facility ❑New EH Program and New Facility <br /> Facilit y ID �I I Program Record ID S2� <br /> Facility Address LF2- S � v�7- <br /> (Please Check the appropriate description and specify Lizenumber of units and pe wept 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# License#(J Mobile Mobile Food Prep Unit--Make Vehicle Type. _ <br /> Registration# License# C <br /> ElTemporary Food Facility----.Dates of operation from r I F t nt <br /> ❑ Special Event --Dates of operation from to—: W <br /> id <br /> DAIRY PROGRAM(2000) 7-D 10— <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Mill:Dis <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator. Tons Generated Per Yc� <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) <br /> Tiered Permitting Facility - 13 Conditionally Autfio <br /> 13 ��� ��Permit-By-Rule Fixes CCU//III��� T'[ Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2340) Num <br /> U"ERGROUND_ST0RAGE TANK(UST)PROGRAM(2300)Use U <br /> HOUSINGPROGRAM(2400) <br /> 11Hotel/Motel Number of Units ❑Jail <br /> Employee Housing(2700)Use F*Pfopee I{ousiaz&abor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local RW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑RN'QCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTt1 PROGRAM(3600) <br /> Numbeer of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of service rooVSpa ❑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 Tr-at e�ntt Plant (3 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) �zg S"- <br /> ❑ Landfill ❑Transfer Station ❑Ag/CanneryWaste Site, ❑SludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIALandfill Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm1R2nch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilied'Nursing ❑Large Generator © Small Generator ❑Limited hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60-•---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS FSHD 46-02-003 Mae Application Form <br /> EMERCt=1 cy Norlr IcATEON FORyms FACILITY ANO/OR PROGRAM <br /> �CONTACI'PERSON- _ N � _ __ Day Ph Night Ph i <br /> PROGRAM ELENIEN r � �! FEE ❑ Surcharge FFE"- e-� [3Other FEE <br /> 1NSPECFOR# n PERMIT VALID L 3�t77 to� 1 b� t7 p ❑ Food Handier(/ <br /> Check# 6 AMOUNT PAID V110„ Qt� Date_ I P111.j D'] INVOICE <br /> ❑ Cash REVIEWED BY 6-0 0 Z AccoUDNTING OFFICE Date <br />