BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 002-&2 Program Record ID Dj Tro3 Facility Address 'IOZO S. G4CVXVy1ev k�) f2k Wdi _ C4 CSC `-(3 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity quare Footage Food Handlers Course required: YESw No ❑ Commissary ❑ Dry storage only Nfwith 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) ❑ PBR(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 Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units P SOLID WASTE PROGRAM (4400) ��.//+'� ElLandfill ❑ Transfer Station 11A Ag/Cannery Waste Site ❑ Sludge/As Qr ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIAk(Qofi)Il Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters >20 cu yd (#of Units) ❑fVn//Ran Ch1@9Tp Site MEDICAL WASTE PROGRAM(4500) pp��EN�VjAQUIN ��,``' ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Genera lCN �M ?4t.wer ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 >'�1'pA ators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form __��YYII'' EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM p CONTACT PERSON,lgtlre` E77f� � Day-Ph- �-g �z7�7� Night Ph Qq 3a-7 �3�7 PROGRAM ELE'MT nENFEE 62-311— /� ElSurch rge EE ❑ Other FEE INSPECTOR# 1" y)�J PERMIT VALID 2.0 t0 1UVZ0Qj ❑ Food Handler ❑ Check# AMOUNT PAID Z �::T r Date=[E�W=o INVOICE# 11Cash UO(REVIEWED BY ACCOUNTING OFFICE Date ZQ 40-02-034 ^O I II�...�/�/1^�/ —�(7" MASTERFILE RECORD IMFORMATION PINK 1/23/13 Ivl ,}Vfl i/-l'i11 Vv1