Laserfiche WebLink
PAYMENT <br /> RECEIVED <br /> SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT JAN 12 2006 <br /> MASTERFILE RECORD INFORMATION FORM <br /> 11 New EH Pro am at ExistingFacility ❑New EH Pro and New FacilitySAN OCOUNTY <br /> '/ ENVVIRIRONNMM ENTAL <br /> FacilityID C7 Pro ram Record ID �osa;,q F/7 M�TH DEPARTMENT <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No❑ <br /> ❑Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units <br /> ❑Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only <br /> Mobile Food Vehicle--Maket2 Lrl Vehicle Type `f3()D Color f,0 <br /> Registration# 7 37, License# ��tJ3 Zef Z, Sticker# <br /> ❑Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility--Dates of operation from - to — 11 Ice Plant <br /> ❑Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser--Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator---------Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(22 18) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housine/Labor_Camo Application Farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> EI Poultry Farm—Maximum number of birds 11 Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill - ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator 0.Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10---❑ 11 -60-13>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMER cy NgVFICATION FORTHis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON ,�L Day Ph 24-2E JtIJI/ Night Ph <br /> PROGRAM EL MENT FEE 10, i/ ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID t)I y(O(-v to ill 31 '0(. ❑ Food Handler <br /> IKICheckN fiq1.3 AMOUNT PAID J>?:;--- DateI/(�OI� INVOICE# ItfyloS <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE�ZeA�_ - Date IIS Of. <br /> 4M2-034 Maslerf le Record Pink <br />