BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility []New EH Program and New Facili Facilit ID l y(O Program Record ID Facility Address j?)6 9-1 DROiii (� I ES(_/M—e (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 Machines 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 S ❑ 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 UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM(2400) ❑ 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 ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 ❑ 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# E3Pumper Yard ❑ Package Treatment Plant 11Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles Is of units) ❑ Dumpsters>20 cu yd(0 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS END 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 2220 FEE 2 13. O O ❑ Surcha3e FEE ❑ Other FEE � PERMITVALID 01 01 10 to J10 INSPECTOR 11 Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date P I_lM{,E t;t1 , f3C-,G,IrjnitrJ tat SAn+� u 2oto , 48-02-034 J MASTERFILE RECORD INFORMATION PINK 11/15/0]