Laserfiche WebLink
48- -03 <br />1/23/13 <br />MASTERFILE RE OR INFORMATION PINK ri-i-V-1/43U2S9 <br />SAN JOAQUIN COUNTY <br />q// •/-/7/5/ight Ph kiatt7iiplt <br />ftrM <br />rfi <br />0 Surcharge FpE <br />to 121N2i4 <br />Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT )6 33 FEE <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />a3 ViSrf REVIEWED BY <br />Ely! RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON / -e Day Ph <br />5- 2 <br />NT 0 Other FEE <br />0 Food Handler <br />INVOICE # <br />Date 1 z- <br /> Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br /> o FamAini <br />Small GeneratorWtetWelyer <br />0 11 - 60 > <br />u <br />„6Q, generators <br />i2 <br />ill <br />CNT <br />20a 2n 4u P <br />Site <br />SAN JOAQUJN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility New EH Program and New Facility <br />OD 0 Os(5 Program Record ID <br />Ai ., , ,7--.-- <br />Facility Address /,36A--'iv,K'_ i_s;------- /94 47A0,---( , <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 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />etail Market----Square footage 0 w/Meat Market only 0 Multiple Dep.p-tments 0 Prepackaged Goods Only <br />III Mobile Food Vehicle --Make a,,,/ Vehicle Type “.1C::› /, /-1 Color t A_I A ; ii---- <br />Registration # License # 1...---(/41TYlr-1 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0CF0 0A0B <br />Facility ID -,r7 <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR 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 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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site <br /> 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa <br /> 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />1:1 Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />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 />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br /> O Ag/Cannery Waste Site <br />1:1 Waste Tire Facility 0 Compost Facility O Process/Recycle Facility <br />Refuse Vehicles (# of units) <br /> <br />O Dumpsters >20 cu yd of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form