Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT <br /> RECEIVED <br /> MASTERFILE RECORD INFORMATION F RM <br /> 13 New EH Program at Existing Facility New EH Program and New Facilit FES 0 9 2016 <br /> Pro ram Record ID 1102 S N NVIRO N COUNTY <br /> Facility ID � 3�� ENVIgOMENTpL, <br /> HEALTH DEPARTMENT <br /> Facility Address <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM It 600) Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Restaurant: Seating Capacity_ Square Footage ❑Vending Machines Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> Vehicle Type Color. <br /> ❑ Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type <br /> License# Sticker# <br /> Registration# ❑ Ice Plant❑ Produce Stand <br /> ❑ Temporary Food Facility--Dates of operation from to <br /> [3 Special Event---Dates of operation from <br /> to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit- <br /> 0 <br /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Faci it ❑ Program 3 Facility <br /> LNIHazardous Waste Generator(2200)------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST)(2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ <br /> ❑ Hotel/Motel-----Number of Units Jail or Exempt Institution----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Fo m <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11Environmental Assessment LJ UST-CAP Site ElLocal HW Cleanup Site ❑ NPLISEP Cleanup Site 11 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility_ ❑ Pool ❑ spa <br /> ❑ Out of Service Pool1Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm-------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM (4200) Ca aClt Vehicle# <br /> [I Pumper Vehicle Registration#. License# P Y <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill LJ Transfer Station ❑ Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility <br /> ❑ Refuse Vehicles l#of units) <br /> L7 Dumpsters> 20 cu yd (#of units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue <br /> <br /> ! <br /> PROGRAM ELEMENT' FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ' �'� PERMITVAUD Q (6 f0 a. f �115U <br /> ❑ Food HandlerCheck# O% AMOU T PAID �� 3 y Date iNVOIGE# ----------------- <br /> �� <br /> ACCOUNTING OFFICE Date <br /> E] Cash REVIEWED BY MASTERFILE RECORD INFORMATION PINK <br /> 48-02-034 <br /> 1/23113 <br />