Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existiris Facility 0New EH Program and New Facilit <br />Facility ID j4-DD 24-0 Program Record ID p(2,751ig <br />Facility Address LI 5 7- Pc9-, N-4 ftirO R—) - <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 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type <br />License # <br />Color <br />Sticker # <br />lce Plant 0 Produce Stand Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from to XICFO A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <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 />0 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 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCE Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <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 # Capacity Vehicle # <br />Pumper Yard <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# 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 <br />8.4NJ0,4 <br />I 4. Date 3 4121 INvoicE# --Sq <br />48-02-034 <br /> ACCOUNTING OFFICE We' <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (tf of units) <br />2-10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON C---64 v <br />PROGRAM ELEMFNIT 10 66 FEE <br />INSPECTOR # PERMIT VALI <br />Check # AMOUNT PAID <br />EYE h v‘69c; REVIEWED BY <br />rRGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />RA 0 I\) Day Ph Night Ph OipAtriir_otafogijAi, EA114/is QUIN C <br />62 0 SurcIparge EE _ 0 Other FEE etkp,„7,AL ' r <br />"vTrAtzavi. <br /> I=1 Food Handler <br />oar <br />r <br />MASTERFILE RECORD INFORMATION PINK 1-tu2Lect <br />/944 Date / <br />Sludge/Ash Site <br />CIA Landfill Site <br /> 0 Farm/Ranchplksup Site <br />rkE•Atr. <br />Small Generator 0 LiniRtiefte. <br />0 >Akeraerytorgb 0 11 - 60 <br />s 2024