BILLING - Laserfiche WebLink

Home Browse Search

i,A _.A - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RFCF ENT MASTERFILE RECORD INFORMATION FORM JON VFO 13 Now EH Program at ExistingFacilityNew EH Program and New Faclll ,/ G Faclll ID 00 O Pro ram Record ID�� ) 023 N� Facility Address (Please check the appropriate description and specify>l134.number of units and pariinant Infarmatlon.) FOOD PROGRAM(1600) ❑Reataurant: Seating CapaGy_ Square Footage Food Handlers Course required: Yas❑ No ❑ ❑Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑w/Meal Market only ❑ Multiple Departments❑ Prepackaged Goods Only CK Mobile Food Vehicle--Make GO� Vehicle Type t Color Registration#. License# fl Sticker# W V� ❑ Mobile Food Prop Unit—Make Vehicle Type Color Registration# License# Sticker# Z. 1:7 ❑Temporary Food Facility—Dates of operation from to ❑Ice Plant❑ Produce Stand ❑Special Event—Dates of operation from to ❑ CFO ❑A❑ 8 DAIRY PROGRAM(2000) ❑Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Muhl-Head Unit_ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑'Hazardous Waste Generator(2200) > Tons Generated Per Year ' ❑Tiered PermitUng 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 and forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Em yes Housina/Labor Camo Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ Uic site ❑Abandoned HW Site ❑ non•NPLISEP Cleanup Site ❑ RWOCS Cleanup Site ❑ Water Quality Remedlation 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 Fane---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 AR FacilitySterillzation(4121) ❑ Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yana ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles(#ofumu) ❑ Dumpsters>20 cu yd Isatunits) ❑ 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 ❑ 2-10 011-60 ❑ >60 generators PUBLIC WATER sysTEM PROGRAM(4600)Use PWS EHD 4602.003 Blue Application Form .r EMERGENCY NOTIFICATION FOR THis FACILITY ANOIOR PROGRAM CONTACTPERSON :TUA'W1-TA- �1LGn.tLX1->R Day Ph Rtl 1j,1j- 13NightPh PROGRAM ELEMENT FEE E3Surchar a FEE E3Other FEE INSPECTOR# ql''((g� PERMIT VALID 6 t0 14Z-3tzzy 13 Food Handier ❑ Check s /�- AMO�UIN]TAP a •UD Date 6 /J INVOICE# 13 Cash REmEwEO BY `i9" ACCOUNTING OFFICE Date 26 /!5- 48-02-034 54&-02-031 MASTERFILE RECORD INFORMATION PINK 1123113