Laserfiche WebLink
PROGRAM ELEMENT\ FEE LI Surcharge FEE 0 Other FEE <br /> <br />INSPECTOR # <br />Check # <br />Cash <br />crols PERMIT VALID <br />OUNT PAID <br />REVIEWED BY -•-•Qçtt <br />to 0 Food Handler <br />?ILO 7-0 INVOICE # <br />i4 Date <br />Date <br />ACCOUNTING OFFICE <br />AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />El New EH Program at Existing Facility -4e\--TEH Program and New Facility <br />Facility ID r7A--Vba-61L/-5 Program Record ID P12.0 .6-4/ 30) I <br />Facility Address Lia,..f E.- fAoiufo5aid _Y-1-bc.070/7 ea qsz-I3 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />Commissary 0 Dry storage only El with Food Preparation 0Vending Machines Number of Units <br />El Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />El Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />C7 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce,Stand <br />Special Event---Dates of operation from to LI CFO OADB <br />DAIRY PROGRAM (2000) <br />ID Grade A Dairy D Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />cu PA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application FOI111 <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 1:1 NPUSEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site El RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa E Out of Service Pool/Spa LI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) LI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) ID Body Art Temp Event Co-ord (4130) LI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />ID Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility LI CIA Landfill Site <br />El Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of Units) 1:] Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care D Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />El Transfer Station El Veterinary Clinic 0 Common Storage Facility El 2- 10 0 11 -60 <br /> LI > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br />45-02-034 MASTERFILE RECORD INFORMATION PINK <br />CONTACT PERSON <br />V23.13