BILLING - Laserfiche WebLink

Home Browse Search

PAY NT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED i�`C1=1V�G MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility []New EH Pro am and New Facility µn 6 „„ �� A[T 2 2005 4 V�S'AId JQAQUIN COUNTY FacilityID Z ( Pro ram Record ID ��5�� 4 /-7 / .may- j� NVIRONMENTAL Facility Address ! /OJ �- I IGwI�'v. Lt)» �ry^ / LTH DEPARTMENT (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)Q.,. ❑ 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 gMobileFood Vehicle---Make Vehicle Type T-S Color_ Registration# License# Sticker# __q3_7(__ ❑ 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 COPA ❑ 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(LIST)PROGRAM(2300) Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution—Norther of Units Employee Housing(2700) Use Employee Housine/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Envirou mental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 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(412 1) ❑ 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—Number of Units ❑ Dumpsters>20 cu yd---Number 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------1:1 >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 iX% 6064i M2S- Day P - Night Ph PROGRAM ELEMENT I<,3 FEE ?S: 0_ ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID �3{123/p,j to_ �'�3 if O S' El Food Handier Check# 12,003 AMOUNT PAID 1.i� 75' C D Date 3 IZ- ZINVOICE# 13� LJ Cash REVIEWED BY ACCOUNTING OFFICE Date L:3 CJS 48-02-034 Masterfile Record Pink 10/6/2003