BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY MASTERM New EH Program at ' NMENTAL HEALTH DEPAP LENT RECORD INFORMATION FORM ❑New EH Program and New Facilitv Facility ID F= 000 11Li3 Program Record ID _ S 2 - Facility Address • 1081 (Please Check the appropriate description and specify size, umber of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity - __- Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only 0 Mobile Food Vehicle -----Make Registration # ❑ Mobile Food Prep Unit—Make Registration # ❑ Temporary Food Facility ----Dates of operation from ❑ Special Event --Dates of operation from Vehicle Type License #_ Vehicle Type License # to �1 S T Food Handlers Course required: -YES ❑ -No. ❑ Vending Machines —Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit COPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator -----------Tons Generated Per Year El 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 ❑ Permit -By -Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST I UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) 'D Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration #_ ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant ❑ Natural Bathing Area ❑ Kennel ❑ Permanent Cosmetics (4122) Capacity Vehicle # ❑ Chemical Toilets -------Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of 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 ----- 112-10 ------- ❑ 11 - 60 ------❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 159C> FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 0493 PERMIT VALID to ❑ Food Handler ❑ Check # - AMOUNT PAID Date_ INVOICE # 11 Cash REVIEWED BY ACCOUNTING OFFICE N CT Date I I7 (� �.- 48-02-034 Masterfile Record Pink 10/6/2003