COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY IWIRONMENTAL HEALTH DEPARMENT MASTERFILE RECORD INFORMATION FORM PA� 13New EH Program at Exist in Facili ew EH Program and New Facility Facili ID co� Program Record ID �� Vje® Facility Address S 30 8 Pac i-Pic AvP S4N JA A' ®3 2olg (Please check the appropriate description and specify size,number of units and pertinent information.) O4QVI FOOD PROGRAM(1600) HEgiT KRONA f 000y ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course require No ❑ ❑ Commissary ❑ Dry storage only ❑ with 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 ❑ 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 ❑ 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 UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-GAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW 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 TA TOO,BODY PIERCING,PERMANENT COSMgjIC PROGRAM(4100) Tattooing(4121) 11 Body Piercing(4120) Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----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 t#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 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGE cY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON eCefj( C--5 Day Ph W3,01cfq7 Night Ph PROGRAM ELEMENT W20 FEE ❑ Surchar& FE ❑ Other FEE INSPECTOR# __ PERMIT VALID -� to 3O ❑ Food Handler [3Check# i AMOUNT PAID Date idl INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �6 ,2s,��3 f7 48-02-034 'jK%l1 INFORMATION PINK 11/15/07