Laserfiche WebLink
4Z <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> Whew EH Program at Existinz Facility ❑New EH Program and New Facility <br /> Facilit 1D pa 1 %y,,,4_5 I 2i Pro ram Record ID <br /> Facility Address _ _1&9-S--s Z:1, <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[hits <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 to ❑ Produce Stand <br /> DAIRY PROGRAM(2WO) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ~-CUPA ❑State Facility Surcharge(2399) <br /> . <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator. --- Tons Generated Per Year _ ❑Recycle I Exempt S31tem(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility 13 Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(ASI)(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 Ern to ee Housht /Labor Cam A licatrorn Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3WO) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HAV Site ❑non-NPIJSEP Cleanup Site ❑R)VQCB Cleanup Site J❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of poolsispas 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) L-.S 11 6 S 9 <br /> 1a�Ii umper Vehicle—Registraton# I WT A'A m _ rcense# 7 ul I'bP7 y-2-- Capacity Vehicle# 1 QZ6 <br /> ❑Pumper Yard ❑Package Treatment Plant, ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station [3 Ag I Cannery Waste Site [1 Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesvRecycle 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 ❑ Stilled'Nursing ❑Large Generator 0 Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--D 2-10 ❑ 11-W.—E]>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS F.FID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR TRIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELEMEN'T FEE © Surcharge FEE ❑ Other FEE <br /> INSPECTOR# LA b PERMIT VALID .\ to 2 ❑Food Handler <br /> ❑ Checks '. i'AMOUNTPAID Date IN-VOICE# <br /> ❑ Cash �•• VIEWED BY ACCOUNTINGQFFICE [� Date <br />