BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTh`CNVIRONMENTAL HEALTH DEPA?cf'MENT RECE ieNT MASTERFILE RECORD INFORMATION FORM Ep ❑ New EH Pro ram at Existin Facility ❑New EH Program and New Facility FEB 0 4 2015 SAN JO Facilit ID #A 00227E Pro ram Record ID ;'�s398L9 "WR JAIfyCOUN HEAITN DEP ENTAL Facility Address Ill 0 0 A! M i 1\ S+ ARTI6IE (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) - ER-Vastaurant: Seating Capacity 17- Square Footage `(30O S''�-f Food Handlers Course required: YES If No El lCommissary 13 Dry storage only 1:1 with Food Preparation— ❑Vending Machines Number of Units ❑ Retail Market---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehible Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------> Tons Generated Per Year ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ CE(2233, 2234, 2235,2237) ❑ PBR(2231) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CU PA Program 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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) 11 Poultry Farm-------Maximumnumberofbirds [I Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) 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 (#of units) ❑ Dumpsters>20 cu yd (#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 EHD 46-02-003 Blue Application Form - EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON_�6S.P ro u.Zm&V Day Ph 204.6/2-zrf Night Ph 209• 86 S" 51 PROGRAM ELEMENT 1(7- FEE � ��tt ^ V1 11 Surcharge FEE El Other FEE INSPECTOR# ( iIIU.LtsA iPERMITVALID �- 7 2- -�-� El Food Handier-- 0 Check# andler_❑ Check# AMOUNT PAID (0• t"IDate INVOICE# D3� Cash REVIEWED 9Y �(;-) v--( )21-�, ACCOUNTING OFFICE 6AVV Date J 44-02-034 - MASTERFILE RECORD INFORMATION PINK Inm,a