BILLING - Laserfiche WebLink

Home Browse Search

Dec 17 2013 2: 37PM Kelly 's Express Car Wash 209 474-5MCEI"Eb SAN JOAQUIN COUNTY Elli1WRONMENTAL HEALTH DEPARTMENT DEC 17 2013 MASTERFILEECORD INFORMATION FORM ❑ New EH Program at ExistingFacilityNew EH P ram and New Faell NVIRONMENTAL HEALTH DEPARTMENT Facili ID Pr ram Record ID 1� Facility Address CreIffA Dri vr_, kfn-n. CA 9521 9 (Please check the appropriate description and specify sizes number of units and pertinent Information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Commissary ❑ Dry storage only 147 with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market--Square footage__ ❑ wlMeat Market only ❑ Multiple Departments❑ Prepackaged Goods Only 13Mobile Food Vehicle--Make Vehicle Type Color Registration# # Sticker# ❑ Mobile Food Prep Unit-Make j Vehicle Type Color Registration# License# Sticker# 1:1Temporary Food Facility-Dates of op ration from to ❑ Ice Plant❑ Produce Stand ❑ Special Event--Dates of operation froml to ❑CFO ❑ A ❑ B DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser;-Number of Containers in Multi-Head Unit COPA �liazarclous Materials Business Plan (1900) Numoer of chemica : �_ ElCaIARP Program Ell Program 1 Facility 1:3Progi 2 Fa ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)-,--->-Tons Generated Per Year ❑ Tiered Permitting Facility------> ❑''CA(2232) ❑ CE(2233,2234,2235,7237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility (AST)(2800) Number ofASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel--Numoe of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700)Use Employee FllousinalLabor Ca mo Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(31D00) ❑ Environmental Assessment ❑ UST-GAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-OPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ p Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of I birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(x ar unks) ❑ Duin pate rs>20 cu yd(a or UniW ❑ FarmiRaneh Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHO 46.02403 B/ue Application Form .n. ^^��,, EM ENCY mFICAT N FOR THIS FACILITY A21OR PROG Night Ph �T--239��3 Z'� CONTACT PERSON TI QA Day Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPrCTOR# y)l Q!E) PERM17 VA.LID to ❑ Food Handier ❑ chw* AMQUnNrP b Date INVOICE# L3 Cash REmEWEDRY I)" (L AccouNTINGOFFICE Date MASTERMLE RECORD INFORMATION PINK a8-02-034 1/23rt