BILLING - Laserfiche WebLink

Home Browse Search

v SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM .New EH Program at Existing Facility []New EH Proand New Facility Facilit•ID 3 2Q Program Record ID Facility Address O /4/ �r $I/ (Please heck the appropriate description and specify s,ize,number Of units and pertinent information.} FOOD PROGRAM(1604) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machines—Number of Units ❑Retail Market—Square footage D 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 0 Special Event --Dates of operation from to D Produce Stand DAIRY PROGRAM(20W) 0 Grade A Dairy 13 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 1 Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule.Fixed Unit D Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2394) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B Le s HOUSING PROGRAM(2400) D Hotel/Motel Number of units ❑Jail or Exempt Institution Number of Units Employee Hoasiug(2700)Use Employee Ifousin e&gbor Camp Appf cation Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) ❑ Environmental Assessment ❑UST-CAP Site 13 Local HW Cleanup Site. D NPLISEP Cleanup Site ❑UIC Site ❑ Abandoned MY Site ❑non-NPIJSEP Cleanup Site 0 RWQCB Cleanup Site '13Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of pools/Spas at Facility ❑Pool D 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) 13 Body Piercing(4120) D Permanent Cosmetics{4122) LIQUID WASTE PROGRAM(42 kiLI'umper Vehicle Regi ion 1F tt CSLicense# kX to7 S3 - Capacity ;L-MOqj.. Vehicle# ❑Pumper Yard 17 Package Treatment Plant. ❑Chemical Toilets N r of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag/CanneryWaste Site D SIudgelAsh Site ❑Waste Tire Facility 11 Compost Facility ❑ ProcesslRecycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles Number of Units ❑Dumps(ers>20 cu yd--Number of Units ❑FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) L Primary Care D Acute Care ❑Skilled'Nursing ❑Large Generator Small Generator ❑Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----D 2-10 D l l-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS FWD M-02-003 Blue Appifcation Farm EMERGENCY NOTIFICATION FOR This FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE © Surebarge FEE '. D Other FEE INSPECTOR# ER.MIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# 13 Cash REviEwFD BY ACCOUNTING OFFICE Date