Laserfiche WebLink
PA) <br /> RCN�E <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JON 2 <br /> MASTERFILE RECORD INFORMATION FORM ?01S D <br /> ❑New EH Pro Yam at Existing Facility ❑NSW EH Pro ram and New FacilityHE,V�°�4eN,u <br /> Facility IPA00;;?,3o a Pr romRecordTD <br /> Faicffity Address tom" S <br /> (Please check the appropriate description and epeeify,ate.number of units end oartinent InfdrmatlonJ <br /> E44D PROGRAM(1600) ' <br /> ❑Restaurant Seating Qapecity_ Square Footage Food Handlera Ccursa ranuired: YES❑ NO ❑ <br /> 13 commissary ❑Dry storage only ❑Wb Fdod PreparoWn ❑Vendlog MAchines Num6erof Units <br /> ❑ Retal tSquare faotage. ❑w/MeatMarket onlyMultiple Departments 13 d Goods OnlyOMobllaO'aodVehiele-•Make V hldeTyp Color-C),i Vn <br /> Reglatratien# nse# <br /> Sucker# <br /> ❑ Mobile Food Prep Unit--Mdks Vehicle Type Color <br /> Registration# Uceiise# Sticker# <br /> ❑Temporary Food Facility,-tletssof operation from _ td _ - f,7 Ice Plant 11 Produce Startd <br /> 1:3Speof,w Event—Dates of-operation from to ❑CFO b A❑8 <br /> DAIRY PROGRAM(2000) - <br /> ❑ Grade A Dalry ❑ Grotto a Dalry .13 Milk Dispenser`Number of Containers in Multi-Head Unit_ <br /> ❑ Hazardous Materials Business Plan(19.00) Number of Memicals: <br /> ❑GaIARP Program ❑ Program 1 Facility El Program 2 Facility O Program 3 Facility <br /> ❑ Hazardous Waste Generatgr(2200) > Tans Generated PerYear <br /> ❑ Tiered Permitting Facility-- > O.CA(2232) O dE(2233;,M4;2235;2237] ❑ PSR(2231) 13 PBR HHW(2236) - <br /> ❑ Aboveground Storage Tank Facility(AST)(2600) Number ofAST$ <br /> ❑Undgrgrcund Storage rank-Program(UST)(2306)Use USIA andB forms <br /> Q Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> Q HoteUMotel—Numberof•Units ❑Jail or Exempt instltudon---Number of.Units <br /> Empidyea Housing(2760)Use Emp/ovea HousfiolLaborCamp Application Fom) <br /> Arm mMOATION(2900) UNDERGROUND 14JECYION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site - ❑ Local HW Cleanup Site ❑ NPUSEPCieanupSite Q UlCsite <br /> ❑Abandoned HW Site ❑nowNPLISEP Cleanup Site O RWCCB Cleanup Site. 13 Water Duality Rgmedlatlo_n Site <br /> g,.pCF(EAndNAL HEALTH PROGRAM(3600) <br /> Numberof Paols79pes <br /> at Fadilty_ .13 pool ❑Spa ❑ Out of Ssrvlee'Pool/Spa d Natural Bathing Area <br /> V9CT0A boNTROL PROGRAM(4D00) <br /> O:Poultry Farm--Maxlmumnumberof,birds O Kennel <br /> TATT60 BODY PIERCING PERMANENT C08MEnC PROGRAM(41 <br /> ❑ Body Art Practitioner Reg(11 1q) I7 Mechantoal OSPS NotiRcatlon(4115) T3.Bbdy Ari FecilityS1491O tlae(4120) <br /> ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Cc-ord(4.130) ❑SAay Alt-Temp Event Moblle Facility(4131) <br /> I Io41O WASTE PROGRAM(4200) <br /> ❑ Pumper Velilcie1keglstraticn.# Ucense# - Capacity - V01gle tF <br /> ❑ P.umperYard ❑ Package Treatment Plant ❑ Chemical Toilets—NumberofUnits, <br /> sour-WASTE PR6GRAh1PR6GRAM(4400) <br /> 17j anrlfiil ❑Transfer Station ❑Ag/Cannery Waste Site [] Sludge/Ash Alto <br /> WaeteTlre Facility [3GpmpostFac)lity ❑ Procees/RecycleFaoUtty 13CIALand011 Site <br /> ❑ Refuse W61cles 0 of Urdo) ❑ DumpstWrs-s29Quyd,(ira yrq)__ ❑ FarmlRanchCleanup Site <br /> MEOIOALWASTE PROG�M(4500). <br /> ❑ Primary Care ❑Acute care 13 Skilled Nursing ❑ Large Generator 13 Small Generator El Limited Hauler <br /> C3Transfer,station E3Veterinary Clinic 13Cbmmoh Stomp ji llity 13.2-10 0.11-00 ❑ >66 generators <br /> aiioL�CWATER�5�M PROGRAM(4600)Use PWS EHD 48.02.00348.02:003 BlueAdDlIcation Fonn (70 rn X <br /> CONTACTPERSON <br /> EMERONGYNOM06ATI"NFd1- �yPtCILITYAft OG MhtPh. _11��2 �`r�U . <br /> gjj� III N19 <br /> FROGRAM ELEMENT. < FEE ❑SUrctiar s F E _ ❑Other FEE <br /> INSPacioa}e__� . PERMITVALID tc / / tFood Handler <br /> ❑Ch6ck# ti Amcuhf RAID ;263.n D DSt$ 5 INVOICE# <br /> ❑Cash REVIEWED BY AccouNTiNd OFF(GE bete lQ zg /5 <br /> 48.02-034 - M&MRFILE R pO,R NF08WT10N PINK <br /> 1&3!13 j <br />