BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY-i'IVIRONMENTAL HEALTH DEPAP �IENT MASTERFIC�"RECORD INFORMATION FORM ❑ New EH Program at Existin Facility ❑New EH Program and New Facility Facilit ID Program Record ID Facility Address V Z - (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) 11 Restaurant. !;Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No 1:1 ❑ Commissary'❑ Dry storage only ❑ with 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.,(2400} ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit Ct1PA ❑ State Facility Surcharge(2399) 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) 0 Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-R Household Hazardous Waste UABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST r� NDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms /< HOUSING PROGRAM(2400) © Hotel/Motel-: Number of Units ❑ Jail or Exempt Institution(- mber of Units Employee Housing(2700) Use Em to ee Housin /Labor Camp A lication Form SITE MITIGATIONA2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 f=arm'------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(41,21) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# 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(#of Units) ❑ Dumpsters>20 cu yd(#or Units) ❑ Farm/Ranch Cleanup Site MEDICALWASTE'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 EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT ZR 140 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 07 PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE- Date p2 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07 � n