BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNT'i ,:NVIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM EH 00 69 ❑ New EH Pro ram at Existing Facility ❑Ncw EH Pro ram and New Facility Facility ID Program Record ID 11-112 Facility Address Lp c rJ (Please Check the appropriate description and specify size,number of Knits 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 Mcat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License It 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 Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Perniit-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(lousing(2700) Use Employee F/orrsing/Labar Caren Application Foran S TE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) Environmental Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas 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 Vchicic--Registration It License# Capacity Vehicle# "- ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilcts-------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 ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10-------❑ 1 I -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E/10069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT S FEE_ zed ❑ Surcharge FEC ❑ Other FEE INSPECTOR# / PERMIT VALID to ❑ Food Handier ❑ Chcek 9 AMOUNT PAJD Date I INVOICE# r_1 Cash REVIEWED BY /•V" ACCOUNTING OPpiCC �� Date -7 EH U069 PINK FORM.doc r. Rev.07/07/99