BILLING - Laserfiche WebLink

Home Browse Search

PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM 11 APR Z 5 %ew EH Program at ExistingFacility ❑Jew EH Pro ram and New Facility2018 FacilityID U Z (off Program Record ID R� / SAN ENVIROOAQUINNMENT COUNTY ENVIRONMENTAL Facility Address ,�� C� I(i i"vV\C_ / ��` C H E4tj AL (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ 'Commissary ❑Dry storage only �ith Food Preparation wending 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 ElMilk 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 USTA 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 Onon-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) LIBody Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) Pumper Vehicle Registration# License# Capacity Vehicle# ❑Pumper Yard LJPackage Treatment Plant Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) LLandfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site Elwaste Tire Facility ❑Compost Facility E" Process/Recycle Facility ❑CIA Landfill Site ❑E'0 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 E1> 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 PERSON �4)26n, 0,2S Day Ph Night Ph PROGRAM ELEMENT L FEE } ❑Surch r e FE' ❑Other FEE INSPECTOR# PERMIT VALID -7 T t0 ❑Food Han2dler ❑Check# AMOUNT PAID / �(/ Date INVOICE# 3D 2 ❑Cash REVIEWED BY ACCOUNTING OFFICE Date 23 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07