BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility El New EH Program and New Facility I Facility ID Program Record ID N Facility Address (exuV Ave (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 ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # A E■ Mobile Food Prep Unit-- Make Vehicle Type Registration # License #- Temporary Food Facility --Dates of operation from Special Event ---Dates of operation from to DAIRY PROGRAM (2000) Color Sticker # to ❑ II[e Plant ElFO tey A ❑ B Produce Stand ❑ 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) ❑ PER 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) �[m� p� El Environmental Assessment ElUST-CAPSite ❑ Local HW Cleanup Site ElNPUSEP ClepaMEa9J UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ WatR"jjVVE9ation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa j f1 F#@rjfijhing Area VECTOR CONTROL PROGRAM (4000) ,�Q UNTY ❑ Poultry Farm -------Maximum number of birds SAN JWP}'NAAL TATtOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ENVIRt�'v HEAITH DEPARTMENT ❑ Body Art Practitioner Reg (4110) 11 body Art Facility -Sterilization (4121 LIQUID WASTE PROGRAM (4200)' ElPumper Vehicle Registration# ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) License # 13Pumper Yard ElPackage Treatment Plant SOLID WASTE PROGRAM (4400) Capacity Vehicle # 11Chemical Toilets —Number of Units ❑ Landfill CITransfer Station ElAg/Cannery Waste Site ElSludge/Ash Site 11Waste Tire Facility 13Compost Facility ❑ Process/Recycle Facility ElCIA Landfill Site ElRefuse Vehicles I# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) L1Primary Care ElAcute Care 11Skilled Nursing ❑ Large Generator L1Small Generator ElLimited Hauler ❑ Transfer Station ElVeterinary Clinic 11Common Storage Facility 1:12 - 10 ❑ 11 - 60 El> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form Apwe 201 5001-9"'/3 CONTACT PERSON LW DayPh�2dq L1q-6jIen3 Night Ph PROGRAM EL F�[,T FEE El Surcharge FEE El Other FEE INSPECTOR#(II l PERMITVALI CCheck # AMO NT PAID S t0 p7 Date 1 Z' El Food Handler INVOICE # '11 rfX,,ash REVIEWED BY ry ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/}3