BILLING - Laserfiche WebLink

Home Browse Search

. . , SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facilitv 43NeW EH Program and New Facility Facility ID fi}Q01 FF(% D Program Record ID Fneilifv Address 25 East Main Street (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) PAYMENT RECEIVED MAR 2 6 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines -Number of Units ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle ----Make Registration # ❑ Mobile Food Prep Unit --Make Registration # ❑ Temporary Food Facility -----Dates of operation ❑ Special Event -- Dates of operation from_ Vehicle Type Color License # Sticker # Vehicle Type Color License # Sticker # to to _ 11 Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit COPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator -----------Tons Generated Per Year ❑ Recycle / Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ----------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms 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 TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Kennel ❑ Permanent Cosmetics (4122) ❑Pumper Vehicle --Registration# License# Capacity Vehicle ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ---Number 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 ---- 02-10 ------- 011-60 ------❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON PROGRAM ❑ Surcharge INSPECTOR# lies -11 PERMIT VALID M I I ON to Check# 100Z- AMOUNTPAID l a'30 • trl7 Date Cash REVIEWED BY Y ,il—Qp rACCOUNTING OFFICE Night Ph 209-603-6264 ❑ Other FEE ❑ Food Handler INVOICE # �-1 *-K n 45-02-034 V L -1a r1/ _ PP -,o �{-Z� Masterfile Record Pink 10/6/2003 tJ cQ s7 -s -D o//