Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> El New EH Program at Existing Facility ONew EH Progam and New Facility <br /> Facility ID ),S-q-D Program Record ID <br /> FacilityAddress \N G10111 lin� �1 �t ,k ,: <br /> (Please check the appropriate description and specify size, number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES No El <br /> 0 Commissary El Dry storage only El with Food Preparation ElVencling Machines Number of Units <br /> Retail Market----Square footage w/Meat Market only 11 Multiple Departments 0 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 /> 0 Temporary Food Facility--Dates of operation from — to 11 Ice Plant 11 Produce Stand <br /> EI Special Event...Dates of operation from to 11 C FO EI A 1:1 B <br /> DAIRY PROGRAM (2000) <br /> El Grade A Dairy El Grade B Dairy El Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> El Hazardous Materials Business Plan (1900) Number of chemicals: <br /> CaIARP Program El Program 1 Facility El Program 2 Facility 0 Program 3 Facility <br /> Hazardous Waste Generator(2200)---------->-Tons Generated Per Year <br /> Tiered Permitting Facility-------> 0 CA(2232) El CE (2233,2234, 2235, 2237) El PBR(2231) 13 PBR HHW(2236) <br /> Aboveground Storage Tank Facility(AST) (2800) Number of ASTs - <br /> Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br /> Other CUPA Program—1?'2 1 '�W`Cl 011 0011 4 h t4)� <br /> HOUSING PROGRAM(2400) <br /> 11 Hotel/Motel------Number of Units Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use EmploVee Houslnq& bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Environmental Assessment 11 UST-CAP Site El Local HW Cleanup Site 11 NPL/SEP Cleanup Site El UIC Site <br /> Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site El Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility El Pool El Spa El Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> 0 Poultry Farm.......Maximum number of birds El Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) <br /> El Body Art Practitioner Reg (4110) Mechanical DSPS Notification (4115) El Body Art Facility-Single Use(4120) <br /> El Body Art Facility-Sterilization (4121) 171 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle Registration# License# Capacity Vehicle# <br /> 0 Pumper Yard El Package Treatment Plant Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> 1:1 Landfill El Transfer Station 11 AgICannery Waste Site El Sludge/Ash Site <br /> El Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 11 CIA Landfill Site <br /> El Refuse Vehicles(#of Units) El Dumpsters>20 cu yd (#of Units) 0 Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> Primary Care El Acute Care El Skilled Nursing 13 Large Generator El Small Generator El Limited Hauler <br /> Transfer Station 11 Veterinary Clinic 0 Common Storage Facility El 2- 10 11 -60 >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 /> CONTACTIPERSON Lglrnw)�Q Ggn7cjw-� Day Ph 2 Oq - 2 LI NightPh o4,1,t qlp) �(pO-62�j <br /> Ir <br /> PROGRAM ELEMENT FEE El Surcharge FEE El Other FEE <br /> INSPECTOR# PERMITVALID to I', Sl 0 Food Handier <br /> C�e� I AMOUNT PAID D.te I-L, INVOICE# 2-- <br /> CaVC5�REVI`EWED BY ACCOUNTING OFFICE I'l Date '5'//,b/ <br /> 48-02-034 V I L)L-/ MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 <br /> 2, <br />