BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F2r6M ❑ New EH Program at Existing Facility New EH Pro ram and NewFacilit Facilit ID b0 �S Program ecord ID QO Facility Address Z�it� F 1�c�l><c yy 5 1 g5 (Please check the appropriate description and specify number of units and Pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/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❑ Produce Stand ❑ Special Event---Dates of operation from to [] CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity P 1 ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of SOLID WASTE PROGRAM (4400) nn�� 11 Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site ❑ SIg IAsa 5100 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ ClA Landfill &14TY ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd I#of units) ❑jgAw hu Site MEDICAL WASTE PROGRAM(4500) E"�H DEPARTMENT ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ^T EM RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph /2P1 )9�5 7'S23J Night Ph PROGRAM ELEMENT FEE ❑ Surchar t-FEE ❑ Other FEE INSPECTOR# �L, PERMIT VALID lib t0 Z ?ro?� ❑ Food Handler ,,� ., ❑ VON �('/�AMOUNTPAID �7 — Date 7-V INVOICE# 7�L� ❑ Cash REVIEWED BY ACCOUNTING OFFICE {—Date 2-0 48-02-034 �1�.�--- ASTERFILE R CO D INFORMATION PINK 0--%1/23/13 % (11,5