BILLING - Laserfiche WebLink

Home Browse Search

Ln JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM '19 New EH Program at Existing Facility ❑New EH Program and New Facilit Facility ID Program Record ID Facility Address 132C) f . (0�� III (Please check the appropriate description and specify size, number of units and Pertinent information.) 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 �jMobile Food Vehicle—Make Vehicle Type Color 11 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 118 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 USTA 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 ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event M f4r,I�I�®1) LIQUID WASTE PROGRAM(4200)❑ 2U21 Pumper Vehicle Registration# License# Capacity Vehi}.uk�L ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) SAN JOAalJN-C"ENVIRONMENTAL ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludWAsW3jgpARTMENT ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#or Units) ❑ Dumpsters>20 cu yd(#of 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 E ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM \\ CONTACT PERSON�.trnf(ti y.wr DayPh'l,C)91` T %— tl NightPh�')yR-(4(Qt PROGRAM ELEMENT FEE � a_. ❑ Surchar a FE ❑ Other FEE IN�SP/€IC�TOR# `1V L PERMITVALID �� t0 —y ❑ Food Handler IJ�c� AMOUNT PAID L b �. �Date T 2v 2/INVOICE# Cash REVIEWED eY ACCOUNTING OFFICE Date 48- 2-034 MASTERFILE RECORD IN ORMATION PINK 1/23/13 C ' ! 2% D L(0 CJ