BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,qY� MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existin Facilit New EH Pro ram and New Facility - , � x_ �—_– _�. and y IVF Program Record-ID �Qj �_ -- S,gH '9 28 Facility Address �C7��- L►.� Saxo�cn} '�� L ,� C � ,?� %N 01`1 �/N 0 19 (Please check the appropriate description and specify size,number of units and pertinent information.) �zTyDONMFN UNry FOOD PROGRAM(1600) Fpq!?rTq� ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No L?NT ❑ 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_ ❑ Recycle/Exempt System(2299) ❑ CRI Offsite Handlers(2218) -------------❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility -------------------El 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 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) ❑ 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# ❑ 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 q EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON \I( �G\_��T�IY01�-r�_� Day Ph 2QCI )A-1 (5 �j Night Ph SG'�►1�Q/ �__ T i PROGRAM ELEMENT FE •�a El5urchar a FE _ El Other FEE �O(J INSPECTOR# _ � PERMIT VALID 3 TT t0 3 Zd 1:1 Food Handier G 1 Check 9 b� AMOUNT PAID Date L�_-- INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date 3 - 48-02-034 MASTERFILE RECORD INFORMATION PINK i vi arm