BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION NIASTERFILE RECORD Ii IFOR IATION FOR1NI (EH 00 69) XNew EH Program at Existing Facility f; ^t ( []New EH Program and New Facility Facility ID PA 001 D 11 g Program Record ID Facility Address 13111 S . PreScott Vc)C_cL , M6_4/IJCCeL- (Please Check the appropriate description and specify size• number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Nlachines —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) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator -----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste IVIABOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST �_ I, DOD UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms +Z�lx HOUSING PROGRAM (2400) ` ❑ Hotel/ivlotel------- Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housi tzlGabor 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 Cl Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of PooWSpas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds C3 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) ❑ 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 C1 Transfer Station 1:1 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) C1 Primary Care C1 Acute Care El Skilled Nursing 1:1 Large Generator C1 Small Generator C3 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 -- ❑ 11 - 60 —❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM !`l1NT !^T DCDcn NT Dav Ph Night Ph PROGRAM ELEMENT O FEE — INSPECTOR # PERMIT VALID ❑ Check # AM ❑ Cash REVIEWED BY ❑ Surcharge FEE to D Date I - Iii' -Z CCO fvriNG OFFICE ❑ Other FEE ❑ Food Handler INVOICE # Date - __. nI,A 7;00