BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED New EH Program at Existln Facility ❑New EH Program and New Facility MAY 1 7 2010 Facilit ID O D gl�j-� Pro rain Record ID � 53 5114 SAN JOAQUIN COUNTY ENVIRONMENTAL Facility Address ZZ C-OA c1-1 -Q -r S7-0 6+--7V S-,D. HEALTH DEPARTMENT (Please.Check the appropriate description and specify size•number of units and pertinent information) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yrs❑ No❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending 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(20W) ❑ Grade A Dalry ❑Grade B Dairy ❑Milk.Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200)' i ❑Hazardous Waste Generator. Tons Generated Per Year _ ©Recycle I 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_lorms HOUSING PROGRAM(2400) ❑ RotcVMotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use E=Iorfe Aousin /Labor Camp A (Weiorr Form SITE MITIGATION(2900) ' UNDERGROUND INJECTION CONTROL(3000) .❑Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL ISEP Cleanup Site ❑UIC Site ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site '❑Water=Quality Remediation Site ' RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑P¢ol ❑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) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) Er(Gb Pumper Vehicle—Registration# ��SY-c S ?✓ Lieense# $G, r3 Dy av�apacity Zoo 6—¢L Vehicle.# X03 Pumper Yard 11 Package Treatment Plant ❑Chemical Toilets Number of Units C SOLID WASTE PROGRAM(4400) ❑Landfill ❑ Transfer Station ❑Ag/Cannery'Waste Site ❑ Sludge/Ask Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,Landfill Site ❑Refuse Vehicles--Number of Units ❑Du npsters>20 cu yd--Nutnber of Units ❑Farm/Ranch Cleanup Site MEDICAL_WASTE PROGRAM(4500) ❑ Primary Care . ❑ Acute Care ❑Skilled.Nursing ❑Large Generator Small Generator ❑Limited Ifauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—t] 2-10 ❑ 11-60--❑>60 generators PURLI C WATER SYSTEM PROGRAM(4600)Use PWS EHD 44-02-00,3 Blue Application Form ]EMERGENCY NoTiricATiON rOR rms FACILITY AND/OR PROGRAM CONTACT PERSON t,J,¢S,f{r,+�'T-D Day Ph 3 ZCl- D'7(orP Night Ph '?S7— Z(^37 PROGRAM ELEMENT �Z`f FEE (150• ❑ Surchara FEF ❑ Other FEE INSPECTOR# T PERMIT VALID 1571-7110 to f R 1 U ❑Food handler ❑ Check# AMOUNT PAID i -e Date l INVOICE# �� 0 Cash REViEWEI)$Y j ACCOUNTING OFFICE Date