BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY 'VIRONMENTAL HEALTH DEPAF ^ IENT MASTERFILL-RECORDINFORMATION FORM fo ❑ New EH Program at Existing Facility New EH Program and New F � I _ M PI Facili ID Dd �a./�F�. Program Record ID Facility Address E . 6 � I � I (Please check the appropriate description and specify size, number of units and ertinen information . /� FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity _ Square Footage Food Handlers ou `l No 13ElCommissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 11 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 Registration # Color License # Sticker # El Temporary Food Facility --Dates of operation from to ❑ Special Event Dates of operation from13Ice Plant to DAIRY PROGRAM (2000) 11 Produce Stand ❑ 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 ❑ 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 LISTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housino/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 11 Environmental Assessment 1:1W UST-CAP Site ❑ Local HCleanup 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) ❑ Poultry Farm -------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ Tattooing (4121 ) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License #. Capacity ❑ Pumper Vehicle # SOLID WASTE PROGRAM (4400) P ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site �Awaste Tire Facility 11 Compost Facility ❑ Sludge/Ash Site El Facility ❑ ❑ Refuse Vehicles (* or units) CIA Landfill Site ❑ 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 1:12 - 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 CONTACTPERSON Da Ph Day Night Ph PROGRAM :EEL:EMEN:T4�:/73:0: FEE ❑ Surcharge FEE ❑ OtherFEE INSPECTOR � T VALIDf0 ❑ Check # PAID ❑ Food Handler Date INVOICE # ❑ Cash ACCOUNTING OFFICE Date 48-02-034 11 /15/07 MASTERFILE RECORD INFORMATION PINK