BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Na.1 EH P_rc_gra_m_at Existing Facility ❑Mex EH Program and New Facile Facitity_ID Program Record ID Facility Address ?;3 4 )P�WC�de— %fe e .5201! (Please check the appropriate description and specify aim,number of units and pertinent Infonnation.) F DPROGRA. (1600) Restaurant: Sealing Capacity_ Square Footage Food Handlers Course required: Yes❑ No ❑ . Commissary ❑Dry storage only 12with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market.---Square footage ❑w/Meal Markel only ❑ Multiple DepaNmonls❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--hake_ Vehicle Type Color _- Registration# License llSticker# ❑ Mobile Food Prop Unit..MakeVehicle Type Color Ragislralion# License# Sticker# ❑ Temporary Food Facility--Dates of operation tram to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dales of operation from to . ❑CFO ❑A ❑ B DAIRY PR. jRAH(2001 ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Coctainers in Mulk-Head Unit C P ❑ 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(2233,2234,2235,22:17) ❑ PBR(2"231) ❑ PBR 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) ❑ HoteliMotel------Number of Units ❑ Jail or Exempt Institution----Number of Un.ls Employee Housing(2700)Use Emulovee Housing/Labor Camp ADrVieatfon Form SITE MITIGATION(2900) UPIDERGROUND INJECTION CONTROL,(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Silo ❑ NPUSEP Cleanup Site Q UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Romedialion Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa O Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONT$OL PROGRA41(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Rag(4110) ❑ Mechanical DEPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Faclfity-Sterilization(4121) ❑Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) UIDWA PROCRAht(4200) Q Pumper VeldcloRegistrallon# Ucense# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units $,OLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑Waste Tiro Facility ❑ Compost Facility ❑ ProcesslRocycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles etofunu) ❑ Dumpstws>20cuyet(Aofunls) ❑ 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 (311-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Usa PWS EHD 46-02-003 Blue Application Form ` r E'IERCENCY OTIFIC TION FOR THIS FACILITY ANDIORFROG RA pyo CONTACT PERSON 1 D'ay Ph J�ligltt Ph •��"I PROGRAM ELEMENT 3-- FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#� t7` PER1.9TVAUD to ❑ Food Handler ❑ Check# AMGuttT PAID Date INVOICE# _ ❑ Cash RF.viEWEDaY ACCOUNTING OFFICE Date 48.02.0:4 101ASTERFILE RECORD INFORMATION PINK 1123113