BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facili ❑New EH Program and New Facili Facili ID Program Record ID Facility Address S C Q533 rD (Please check the appropriate description and specify size,number of units and ertinent information l o 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 ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration# Lie ense# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ 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 USTA 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-NPUSEP 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 ❑ Naturoi Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ,,. CLTittoolnp.(4121) ❑ Body Piercing(4120) 11 Permanent Cosmetics(4122) 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) ❑ Dumpslers>20 cu yd I#of units) ❑ FannlRanch 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 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form MERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON Day Ph 4 -S�oC1-� ight Ph F ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE # PERMITVALID LO ❑ Food Handler AMOUNT PAID Date INVOICE#REVIEWED BY ACCOUNTING rOFFICE Q Date 48-02-034 I�%�� I V V\ fit" ` •J S Z TE E REGARD INFORMATION PINK 1111q`07