BILLING_2017 - Laserfiche WebLink

Home Browse Search

Ag/Cannery Waste Site Process/Recycle Facility Dumpsters > 20 Cu yd (# of Units) Sludge/Ash Site CIA Landfill Site Farm/Ranch Cleanup Site .-\ SAN JOAQUIN COUNTY iIRONMENTAL HEALTH DEPAF ENT MASTERFILE RECORD INFORMATION FORM N\i;k\lew EH Program at Existing Facility 0New EH Program and New Facility Program Record ID Facility ID F/:(2.6) j 5f3 (Please check the appropriate description and specify size, number (7 of)units and pertinent information.) co Facility Address Q --NO 4-z r A-ii uig_ FOOD PROGRAM (1600) NE_Ai, Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES No Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units _Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only AMobile Food Vehicle --Make Vehicle Type Color Registration # )Mobile Food Prep Unit-- Make Registration # Temporary Food Facility --Dates of operation from Special Event---Dates of operation from License # Sticker # Vehicle Type Color License # 4 1—y,..i ( )6) -2.. Sticker # to 0 Ice Plant 0 Produce Stand to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) El Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) > Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) Aboveground Storage Tank Facility (AST) (2800) Number of ASTs Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station Waste Tire Facility 0 Compost Facility Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 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 PERSON2re.i 4-3,2 /1-e) Day Ph ZC'cr 2-2q V5aq Night Ph e-- PROGRAM ELEMENT /'7,..------- FEE c,1 5 --r-' 0 Surcharge FBE 0 Other FEE INSPECTOR # z--P5Y (-7 PERMIT VALID rfe-c-07 to 127[31//7— 0 Food Handler Check # Vic-,. AMOUNT PAID 02 7. DO Date INvoicE# Cash REVIEWED BY ., ACCOUNTING OFFICE °.(3(•,7,6 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units 48-02-034 1/23/13 Date 2?--7 MASTERFILE RECOR INF RMATION PINK