Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proaram at Existing Facility ❑New EH Proaram and New Facilitv <br />Facility ID fljOO� Program Record ID 41knQ <} 42L <br />Facility Address '-ALIS (,U , W,9 ber- AVt , S%OQ/- 0n , LPr- yCa-O 3 <br />(Please check thet d i ti d i b f it d rt' o f It <br />ew <br />RE '40 <br />MAR 0 4 1022 <br />c approriaa pescr p on an specify s ze, num er o un s an pe men norma on.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage <br />NwIN C%�/Al ry <br />Food Handlers Course reouire�! Tql <br />❑ Commissary ❑ Drystorage only El with Food Preparation <br />❑Vending Machines Number of Units P riW NT <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility -Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housino/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas 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 />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <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 />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd wof units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12 - 10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON Day PhCoV.gSS-HlrYl NightPh <br />PROGRAM ELE NT FEE ❑ Surcha e E ❑ Other FEE u <br />INSPECTOR# PERMIT VALID &Z% <br />�`f 2L to `3 3l ❑ Food Handler <br />❑ Check # A OUNT PAID Com• bd Date I INVOICE # G 5 <br />❑ Cash REVIEWED BY M ACCOUNTING OFFICE Date �{ ?2- <br />48-02-034/ ,z/I{- <br />�� �� MASTERFILE RECORD INFORMATION PINK <br />1123113 ` <br />