Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />. MASTERFILE RECORD INFORMATION FORM <br />EH <br />RFCF �� T <br />.lqN 30 <br />S NJOgQUI ?023 <br />Facility Address � (1 %Y1? F <br />/v� Ss (;c �ti HIV <br />EAL HQE eC0LIyn <br />(Please check the appropriate description and spedfy s e, number of units and pertinent Information:) - RIV <br />- <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity_ Square Footage <br />Food Handlers Couras renu[red; Yes 0 No 0 <br />❑Commissary 11 Dry storage only ❑ vAth Food Preparation <br />OVending Machines Number of Units <br />0 Retail Market ----Square footage _ 0 WlMeat Market only <br />0 MultipleDepartments❑ Prepackaged Goods Only <br />O Mobile Food Vehicle --Make Vehicle Type <br />Color. <br />Registration # License # <br />Sticker # <br />O Mobile food Prep Unit --Make. Vehicle Type.. <br />Color <br />Registration # License # <br />Slicker # <br />❑ Temporary Food Facility --Dates of operation from, <br />to 0 Ice Plant 0 Produce Stand <br />0 Special Event ---Dates of operation from to <br />0 CFO 0 q B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy 0 Grade 8 Dalry ❑ Milk Dispenser -Number of Containers ImMUIb-Head Unit - <br />CUPA - <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />0 CaIARP Program 0 Program 1 Facility 0 program 2 Facility ❑ Program 3 Facility <br />0 Hazardous Waste Generator (2200) -------- ->-Tons Generated Per Year <br />0 Tiered Permitting Facility -------> 0 CA (2232), ❑ CE (2233, 2234, 2235, 2237) 0 PBR (2231) ❑ 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 />HOUSING PROGRAM (2400) <br />0 Hotel)Motel ------ Number of Units 0 Jail or Exempt Institution - Number of Units <br />Employee Housing (2700) Use Employee Housfnall-abor Camp Application Form <br />SITE MITIGATION (2900) . UNDERGROUND INJECTION CONTROL (3900) <br />0 Environmental. Assessment 0 UST -CAP Site 13 Local HW Cleanup Site 0 NPL/SEP Cleanup Site ❑ UIC Site <br />0 Abandoned. HW Site 0 non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site -0 Water QualityRemediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />.Number of Pools/Spas at Facility _ []Pool ,Spa ❑ Out of Service Pooll.Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />OPoultry Farm ...... =Maximum number of birds 0-Ke_nn_el <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />D Body Art Practitioner Reg (4f 10) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility -Single Use (4120) <br />[]Body Art Facility-Sterilization(4121) El Body Art Temp .Event .Co-ord'.(4130) 13Body Art -Tamp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />O. Pumper VehicleRegistration# License# Capacity Vehicle# <br />O Pumper Yard O Package Treatment Plant O Chemical Toilets ----Number of Units.-. <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill 0 Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Slte <br />-El Waste Tire Facility 0. Compost Facility 0 ProcesslRecycle Facility 0 CIA Landfill Site <br />0 Refuse Vehicles (#of units) 0 Oumpsters> 20 cu yd (# of units). ` 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 ❑ Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 0 Common Storage Facility O 2.10 11 - 60 0,>.60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />(EMERGENCY NOTIFICATION FORTHIS FACILITYANDIOR PROGRAM <br />CONTACT PERSON S Day Ph �- ' ightPh 9e5- 2}6 - !011 <br />PROGRAM ELE . I ,h m FEE 0 Sur cl2 rge EE ❑ Other FEE <br />INS 4- PERMIT -VALID _- 'L3 to ` 3l 2 ❑ Food Handley <br />OCheck# G-- AMOUNTPAID .Z.� Date INVOICE <br />1:1 Cash REviEwED BY ACCOUNTING OFFICE Date <br />18-02-034 - - - MASTERFILE RECOM INFORMATION PINK <br />1!23113 <br />CW. 15�37o�lg <br />