Laserfiche WebLink
'SAN JOAQUIN COUNTY ENVIRONMI{1NTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD"INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit y ID ecord ID Pip 531, 1 -u�- <br /> Facility Address IQI f, �)kfc,►A LA r Sioc.��y� <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 Elwith Food Preparation ❑Fending 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# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 11 Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> ❑ Special Event —Dates of operation from to 11 Produce-Stand <br /> DAIRY PROGRAM(2000 <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) I <br /> ❑Hazardous Waste Generafor.� Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) 0.Appliance Reeyclers(221 7) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By Rule Fined Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenjotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Fmployee HousinKobor Camp Application Forst <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAF Site 11Local IIW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HIV Site ❑nou-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(36N) <br /> Number of Pools/Spas at Facility. 11P®ol 11 spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds 11 Kennel <br /> 'TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle-# <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> [I Landfill 13 Transfer Station 11 Ag I Cannery Waste Site 11 Sludge/Aslr Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process(Recycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 0,Primary Care ❑ Acute Care ❑ Skilled"Nursing ❑Large Generator Cl Small Generator ❑Limited hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePIVSfHD 46-02-003 BlueApplicafian Form <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_ Day Ph Night Ph <br /> i <br /> PROGRAMELENIENTT �sao _ IEE 303 ❑ SurchargeFEE . ❑ Other FEE _ <br /> IQ6.\4__SPECTOR# Q6 __ PERMIT VALID�. 1 1 l� t0 a13111 ❑ Food Handler <br /> CJ Check f AMOUNT PAw fd(I�l.2Date INVOICE# .--- <br /> �] <br /> Ca 12L-VIEwED BY ��-- ACCOUNT11dG OFFICE Date �� <br />