BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DE, PARTAIEN MASTERFILE RECORD INFORMATION FORM New Eli Program at Existing Facility ❑New EH Program and New Facility_ Facility ID(9(r%�j Program Record II� Facility Address 70d fi07`%l Z -h7-/ D (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity _ ❑ Commissary ❑ Dry storage only ❑ Retail Market —Square footage_ ❑ Mobile Food Vehicle ---Make _ Registration # _ ❑ Mobile Food Prep Unit—Make _ Registration # _ ❑ Temporary Food Facility ----Dates of operation from ❑ Special Event —Dates of operation from #ow Square Footage Food Handlers Course required:. YES ❑ No ❑ ❑ with Food Preparation ❑Vending Machines —Number of Units ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy Vehicle Type License # Vehicle Type License # to to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand n ❑ Milk Dispenser—Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) IIAZARDOUS WASTE PROGRAM (2200) i ❑ 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 em -lit -By -Rule Household hazardous Waste WAROVEG40UND STORAGE TANK FACILITY (AST) (2390) Number of AST 11ZC.,00 6T.41—i-ON TA A Y- , . UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B orms HOUSING PROGRAM (2400) ❑ Ilotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units Employee housing (2700) Use F,mployee ILousin,g/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30W) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPLJSEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPLJSEP Cleanup Site ❑ RNN'QCB 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) 11 Landfill 13 Transfer Station El Ag I Cannery Waste Site [1 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/Raoch 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 ---El 2 - 10 ❑ 11 - 60 -----❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIKS FILD46-02-003 BhreApplication Fora: CONTACT PERSON PROGRAM ELENIENr INSPECTOR # ❑ Check # 0 Cash REVIEWED -BY EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM 4 l 11aE I/ n Day Ph q?1- rr(3 Night Ph FEE PERMIT VALID . ❑ Surcharge FEF to AID /-- Date ACCOUNTING OFFICE ❑ Other FEE ❑ Food handler INVOICE # Date ��i