BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility -ONew EH Program and New Facilit Facili IDF4 60 2Z2 Program Record ID Facility Address Q L/ LTA (Please check the appropriate description and specify size, number of units and pertinent inforrnatlon.) 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 PFO ❑ A 9�B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ff Hazardous Materials Business Plan(1900) Number of chemicals: wY��Q, tl ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility �1 ' ❑ Hazardous Waste Generator(2200)-------->-Tons Generated Per Year F r ❑ Tiered Permitting Facility-----> [ICA(2232) ❑ CE(2233,2234, 2235,2237) ❑ PBR(2231) ❑ Pl��j,li_W�WD 11 Aboveground Storage Tank Facility(AST)(2800) Number of ASTs 2 ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms JOgQU/ ?�47 ❑ Other CUPA Program N �ONNFNTUN7Y HOUSING PROGRAM(2400) FP,yR q( ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution--Number of UnitsFNT Employee Housing(2700) Use Employee Housingl5bor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWOCB 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 Coord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) 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 I#of units) ❑ Dumpsters>20 cu yd (#or 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 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02-003 Blue Application Form n ��r1A . EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM / CONTACT PERSON I �C 1 .S A 4,PGc Day P -7 Night Ph a©G1 7 L[y OZ 3 7 PROGRAM ELEMENT ,,.� yD FEE �3l0• Q 0 ❑ Surch/a,7ge F E ❑ Other FEE INSPECTOR# ��/ PERMIT VAL ��- 2,I> t0 1`J .2 ❑ Food Handler ❑ Check# (�yyL_G 1 AMOUNT PAI 3 Date 1'12-6 20 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE 4M, Date (-j 4&02-034 /' /�� MASTERFILE REO INFORMATION PINK 1/23/13