BILLING_2015 - Laserfiche WebLink

Home Browse Search

LI Surchafge FEE to Date CI Other FEE 0 Food Handler INVOICE # (Please check the appropriate description and specify size, number of U its and pertinent information.) L) ct FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 0 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 Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # 2-2 Mobile Food Prep Unit-- Make Vehitle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to CI CFO 0A0B OSCA-4- I*. r DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Daily 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals: 1=1 CalARP Program 0 Program 1 Facility CI Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) > Tons Generated Per Year El Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) El PER (2231) D 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 CUPA Program HOUSING PROGRAM (2400) 0 Hotel/Motel Number of Units El Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site D 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 E Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) El Poultry Farm Maximum number of birds E Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) CI 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 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) IE1 Landfill 0 Transfer Station 1=1 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility f=1 Process/Recycle Facility 0 CIA Landfill Site E Dumpsters > 20 cu yd (# of Units) -• SAN JOAQUIN COUNTY i_...VIRONMENTAL HEALTH DEPAR. mENT MASTERFILE RECORD INFORMATION FORM 0 New EH Program at Existing Facility ONew EH Program and New Facility Facility ID D Program Record ID ?ig-A5-3? za 7 75 15c -1L Facility Address (.) v‘. -/ A JAN 2 0 2015 ENVIHONNIUNT HEALTH PEHMIT/SEHVICES Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator LI Small Generator El Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 LI > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EM RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph(267).2c,r, 2 4 5-11- Night PI(,-)--C ci) 5 2c) )Fi 0 Farm/Ranch Cleanup Site PROGRAM ELEMEN /6 FEE INSPECTOR # 44XiA-iief- PERMIT VALID AMOUNT PAID 48-02-034 Check # LI Cash mASTERFILE RECO ,D INFORMATION PINK Date Xz3A5— REVIEWED BY i'vit iPri /7.-1—ACCOUNTING OFFICE 101111