BILLING - Laserfiche WebLink

Home Browse Search

.SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT /�q Y MASTERFILE RECORD INFORMATION F RM 4i FcNr ❑ New EH program at Existing Facilit 81 ew EH Program and New Facilit J FacilityID ZX�2 D S Program Record ID "F7,572— N� AN ,32Z2 Facility Address 1�Q �� P��1 ' �SZgC t0gQN/N o (Please check the PROGRAM(1600)appropriate description and specify size,number of units and pertinent information.) Th'O�PAR7MFN7Y FOOD ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ Commissary ❑ Drystorage 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# ❑ Mobile Food Prep Unit..Make Vehicle Type Color Registratlon If License# Sticker# ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event--Dates of operation from to krCFO 1�A 1113 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: ❑ CaIARP 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 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 Housing7LaborCamp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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(413 1) 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(#of units) ❑ Dumpsters>20 cu yd I#or 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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02.003 Blue Applicadon Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CC CONTACT PERSON Day Ph -ID , Night Ph (?,CM)W3-(P!'�TT✓q dl PROGRAM ELEMENT FE ❑ Surcharge FE -71- 11 Other FEE INSPECTOR#- PERMIT VALID - to ❑ Food Hannddler - ❑ Check# Vf - AMOUN 'P1AID _ Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �' p 46-02-034 /�� MASTERFILE RECOR INFORMATION PINK 1/23/13