BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEARTIIENT MASTERFILE RECORD-INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility k Pro ram Record ID $ Facilit ID Facility Address Z 0 ' + 6 (Please Check the appropriate description and specify s,�g number of units and ertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course re wired:- Yrs❑ NO❑ (3 Commissary 13 Dry storage only 13 with Food preparation Elven ding Machines Number of Units El Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments [3 Prepackaged Goods Only Vehicle Type Color ❑ Mobile Food Vehicle-----Make License# Sticker# Registration# Color ❑Mobile Food Prep Unit—Make Velacle Type License# Sticker# Registration# ❑to Ice Plant _ ❑Temporary Food Facility--Dates of operation from El Produce Stand ❑ Special Event --Dates of operation from t0 IDAIRY PROGRAM(2000) ❑ Grade A Dairy ❑Grade B Dairy ©Milk Dispenser---Number of Containers in Multi-Head Unit b CUPA ❑ State Facility Surcharge(2399) ELWARDOUS WASTE PROGRAM(2200) 1 [I Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Eze1. xnpt S17ut(2299} ©CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(21 ) 17) Tiered Permitting Facility------------❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CH) ❑Peraut By Rule Fixed Unitt-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of ASTUrmZs UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B HOUSING PROGRAM(2400) ❑ IIotellMotel Number of Units [I jail or Exempt Institution Number of Units E' toyee Housing(2700)Use EELp ffousin /Gabor Camp Application Form UNDERGROUND INJECTION CONTROL(3000) SITE MITIGATION(2900) .❑Environmental Assessment ❑UST-CAP Site ElLocal UW Cleanup Site• ❑NPLISEP Cleanup Site ❑UIC Site 13 Abandoned HW Site E7 non-NPI.ISEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Quality Remediation Site >fiECR1=ATIONAL HEALTH PROGRAM(3600) Number of PoolslSpas at Facility. 13 Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area. VECTOR-CONTROL PROGRAM(4000) ❑Kennel 0 Poultry Farm Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent CosmMics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# (] pumperYam ❑Package Treatment Plant• ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill 11 Transfer Station 11 Ag/Cannery Waste Site ❑ SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility E7 CIA.Landfill Site ❑Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd Number of Units ❑ Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator Small Generator ❑ Limited Hauler ❑Transfer Sfation ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10 © 11-60----❑a 60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PI'S EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FORTHIS FACILITY ANCIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT Q FEE ❑ Surcharge FFE'. ❑ Other FEE INSPECTOR# ERMIT VALID to ❑Food Handler ❑ Chcck# AMOUNT PAID Date INVOICE# 11 Cash lZFv1 WEI)BY ACCOUNTING OFFICE Date s: { AA�crr lr R�rnrA pin