BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORMpPq ycM 1:1New EH Program at Existing Facility ❑New EH Proram and New Facility `1 1�D Facility ID Z Program Record ID 4 g sq APR 15 20 Facility Address US P)� 1 Sam 1�r.. p)u-0 I--C4brra> 95 "1U FN''0,gQul ?1 (Please check the appropriate dascdptlon and specify size.number units and pertinent Information.) NFq�7H DFP COUNTY FOOD PROGRAM(1600) 4R7- At ❑ Restaurant Seating CapacitySquare Foolage Food Handlers Course reaulred: Yes ❑ No QT ❑ Commissary ❑ Dry storage only ❑wllh Food Preparation ❑Vending MachlnesNumber of Units ❑ Retail Market----Square footage ❑wlMeat Market only ❑ Multiple Departments❑ Prepackaged Goods Only 171 Mobile Food Vehicle-Make Vehicle Type Color Registration# License# Sticker# 1:1Mobile 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 aCFO I$A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dalry ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-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 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 Aand B forms ❑Other CUPA Program HOUSING PROGRAM (2400) ❑ HolallMotel--Number of Una•; ❑ Jail or Exempt Institution --Number of Units _ Employee Housing (2700) Use Employee Houslna/Labor Camp Application Form SITE MITIOATION(2900) UNDERGROUND INJEGI1Qri-4UN1 RUL (:10110) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP 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 (.1100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (41 16) ❑ Body Art Facility-Single Use 141?0) ❑ Body Art Facility Sterilization(4121) ❑ Body Art Ternp Event Coord (4130) ❑ Body Art-Temp Event Mobile Facility 013 1) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegmtrahon# License a Capacity Vehicle# _ ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units _ SOLID WASTE PROGRAM (44(x) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tim Facility ❑ Compost Facility ❑ Process/Racyclo Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(Po a,,%, ❑ Dumpslars> 20 cu yd ,r,,I i�„a,� ❑ FarmlRanch 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 ❑ 11 -fil) ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form E-MEROENCY NOrIRCATION FOR This FACILITY AND/OR PROGRAM CONTACTPERSON C Day Fill O NightPhU50_3Di437U PROGRAM ELEMENT ' FEE I S 5 —_ ❑ Surcharo FEE ❑ Other FEE INSPECTOR L`(*ho. 8 PERMIT VALID to c� O 11 Food Handier ❑ Clunk s ISG.-- AMOUNT PAID •0Date .7 INVOICE# S ❑ Clint, REVIEWED BY ACCOUNTING OFFICE Datef2_� 49-02036Cc- _ d MASTERFILE RECO INFORMATION PINK 1!27117 �I