BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Prooram at Existlna Facilitv ®New EH Proaram and New Facility Record ID Facility Address 19555 South Mountain House Parkway, Mountain House, CA 95931 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) © Restaurant: Seating Capacity ° Square Footage =200 Food Handlers Course required: YEs El 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 Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B 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 Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ��PAYMENT 11 Spa ❑ Out of Service Pool/Spa ❑ Natural Batfi'ing-�tFAD ❑ KenneDEC 0 5 2022 TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) >IAN.IOAOVIN COUNIY LNVIRONMCKIAL Ll' RIMENI �11/�L111p ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) 1:1 Body Art Facility -Single Use l l ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles t#o(Units) ❑ Dumpsters> 20 cu yd (4 of Units) ❑ FarmlRanch 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 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Sharon Wright Day Ph(909)569-7545 Night Ph (909)569-7545 PROGRAM ELEMENT UO t ` FEE ❑ Surcharge FEE ❑ Other FEE INSPECTORO \� \r�Ly eS PERMITVALID \2��" IO 1 .Z_� f❑ Food Handler 11 Check # �% t5 n AMOUNT PAID 1 52Date ?q 5 2-V2--� 2-1--I11 # E]/.r'r/ Cash REVIEWED BY ACCOUNTING OFFICE Date 1/23/723/1 10:19 3