BILLING - Laserfiche WebLink

Home Browse Search

SCAN JOAQUIN COUNTYI;VIRONMENTAL HEALTH DEPA' jENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facill!X ❑New EH Program and New Facilit Facility ID 13-n Program Record ID Facility Address OM5V,64ernai [N Cd' 4524 _ (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) a [3-Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 13No El[3Commissary ❑ Dry storage only [3with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility–Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) ` d HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility------------------ ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Pen-nit-By-Rule Householq Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST 1 -j 9- 04, UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms CT� HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700)Use Employee Housin /Labor CaM2 AppLication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm----Maximum number of birds ❑ Kennel TATTOO,_BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) '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 R of Units) ❑ Dumpsters>20 cu yd (#or Units) ❑ Farm/Ranch 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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT ❑ Surcharge FEE 1:1 Other FEE INSPECTOR# 1411' �.' PERMIT VALID 3 -57110 to 'AY31[1 D ❑ Food Handler ❑ Check# AMOUNT PAID DateVlf) INVOICE# —r— ❑ Cash REvIEwED BY ACCOUNTING OFFICE L46 Date 3 Ivi I Ito I 48-02-034 MASTERFILE RECORD INFORMATION PINK 11!15107