Laserfiche WebLink
EMERGENCY OTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />70 CONTACT PERSON Slivte--3( rf Day Ph 5-10 -750-0 Night Ph 57V -70 <br />PROGRAM ELEMENT FEE <br />INSPECTOR # PERMIT VALID <br />0 Checr AMOUNT PAID <br />0 Cash REVIEYvED BY G <br />0 Surch go EE <br />tO <br />Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />0 Food Handler <br />INVOICE # <br />Date <br />48-02-714 KIASTERFILE REC RD ORATION PINK 101,13 <br />o. DO <br /> .....msommi areemPm•IMAXONIIr-1,4MMIIIPMIRMNIm'IMITINMAMmeomi.‘owm • <br />I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />(Please check the appropnate description and specify size, number of units and pertinent information ) <br />-4 FOOD PROGRAM (1600) <br />- gRestaurant Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />v 0 Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />, 0 Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-Make Vehicle Type <br /> C Registration # License # Sticke°r Ittor <br />0 Temporary Food Facility -Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event—Dates of operation from to 0 CFO 0 A 0 B , <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals' <br />0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200)-------->- Tons Generated Per Year <br />0 Tiered Permitting Facility -----> 0 CA (2232) 0 CE (2233, 2234, 2235. 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />MOUSING PROGRAM (2400) <br />0 Hotel/Motel -:----Number of Units 0 Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Peols`Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm—Maximum number of birds 0 Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration # License # Capacity Vehicle # <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles Iofu ,Isi 0 Dumpsters > 20 Cu yd ofun ts 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 0 >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Pq1 /4 . <br />PP ••Ci v„ <br />CO <br />-1,4 New EH Proaramiat Existing Facility ONew EHI!rram and New Facility SA A,41 <br />23 2023 F;;I-F/002-7 562_, Program Record ID 7-12,05q-826.21 J0,4 n <br />-itid/Airt/i&CtiliA/A1 CO( Facility Address 464o E_Vlookwoork rkve_ j tcr E.CA , Cfc A R 74,47.