BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Pro am at Ezistin Facility New Ell Pro and New Facility— Facility acilityFacilit•ID L ^` C> u Program Record ID 5 2 Facility Address �� `" �� 95--3?-7 (Please Check the appropriate description and specify sizenumber of units and pertinent in ormation) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquareFootage Food Handlers Course required:. Yrs No ❑ O Commissary ❑ Dry storage only D 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# /(7 Mobile Food Prep Unit—Make Vehicle Type Color d 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 Dalry ❑Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) IIA7,ARDOUS WASTE PROGRAM(2200) i [3 Hazardous Waste Generator. Tons Generated Per Year -❑ Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) s ❑ Appliance Recyolers(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) - ❑Hold/Motel Number of Units ❑Jail or Exempt Institution—Number of Units Employee housing(2700)Use Fmplovee)fousine/La6or Camra Application Form SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) 11Environmental Assessment 13UST-CAPSite 11 Local HW Cleanup Site. 11NPIAEP Cleanup Site ❑UIC site ❑Abandoned I1W Site ❑non-NPMEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Poel/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) _ El Poultry Farm—Maximum number of birds E3 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) ❑ Landfill ❑ Transfer Station ❑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 ❑FarmlRanch 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--O 2-10—❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS F[rD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACTPERSON 0-lr4--Tr7tt-c �) tg+Er-A-qS cy-c� Day Ph 9-Z0-3255 Night Ph S-3Z- �6aC PROGRAM ELEMENT ((o 3 Z FEE tet-/ ❑ Surcharge FEE - ❑ Other FEE INSPECTOR# /to C PERMIT VALID D \() to "0 I C) ❑ Food Handler ❑ Chmk# AMOUNT PAID Date INVOICE# ❑ Cash REviswm)uy .?i u ACCOUNTMG OFFICE Date \1 2-1t lD