BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT + MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID Program Record ID .facility Address 7Imo\ SVy- Ed - Li Y-1ce)n C'R 9SZ3Cp (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 Calor Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration # License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice lant ❑ Produce Stand ❑ Special Event---Dates of operation from to VCFO OYA ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy r de B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Bo• i' of chemicals: ❑ CaIARP Program ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2100)----- .. . aerated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboyeground 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 Housinq/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 ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) ❑ 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 I#or units) ❑ Dumpsters>20 Cu yd (#of units) ❑ Farm/RanGJeanup Site MEDICAL WASTE PROGRAM (4500) ��►``1I jj��M�.��, ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Li n' ❑ Transfer Station El Veterinary Clinic El Common Storage Facility El - 10 11 11 -60 ` 4 by generale PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form MSV?y EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM $NJIFIQV/N �0�� CONTACT PERSON I,JLr(��G1Y` Day,Ph Z�CL3�-( �� Night Ph y SRO CO PROGRAM ELEMENT I. U0 FEF{` I i i 'y ❑ Surcharge FEE ❑ Other FEE rAfFivr � INSPECTOR# PERMIT VALID t0 ❑ Food Handler ❑ Check# AMOUNTPAID ( mrg,-- Date X22 INVOICE# ❑ Cash A- REVIEWED BY II �(� ��/J� ACCOUNTING OFFICE RM Date - 48-02-034 �y/�/ MASTERFILE RECORD INFORMATION PM 1/23/13 • 13��'l"IIX�