BILLING - Laserfiche WebLink

Home Browse Search

r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIIIENT MASTERFILE RECORD INFORMATION FORM ew EH Program at Existin Facility ❑INew EH Program and New Facility Facili(I ID Pro ram Record ID Facility Address (Please Check the appropriate description and specify s.!m number of units and pertinent In orrnation,.} FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines.-Number of Units ❑ Retail Market---Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Alobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility---rDates of operation from to ❑ Ice Plant Q Special Event --Dates of operation from to ❑Produce Stand k DAIRY PROGRAM(2000) © Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(.2200)' t ❑hazardous Waste Generator. Tons Generated Per Year D Recycle f Exempt System(2299) © CRT Offsite Handlers(2218) D Silver Only(2222) D Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) D Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Wastc ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST MBIDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use US7 A and BLrms HOUSING PROGRAM(2400) ❑Hotel/Motd Number of Units .❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Fm to ee flousin /Labor Camp Apnficadoa Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) © Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPIISEP Cleanup Site D UIC Site D Abandoned HAV Site ❑ non-NPIAEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site RECREATIONAL 14EALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 ❑Spa ❑Out of Service PoollSpa ❑ Natural Bathing Area VEGTOR.CONTROL PROGRAM(4000) El Poultry Farin 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) ❑ Landrtu ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA•Landtill Site ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site MEDICAL.WASTE PROGRAM(4500) ❑ Primary Care ' D Acute Care © Skilled Nursing ❑Large Generator D Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----0 2-10 ❑ 11-60---❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS ERD 46-02-003 Blue A licafiorn Form EMERGENCY NOTIFwATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph �5—_WWIght Ph&90f_-_j25 =7 PROGRAM EL hi NT FEE ❑ Surcharge Fes ❑ Other FEE INSPECTOR# PF_Pmrr VALID to ❑Food Handler ❑ Check IV AMOUNT P 1D Date INVOICE# El Cash REVIEWED BY ACCOUNTING OFFICE Date