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 ID120S±DI '] Facility Address `020 \ — (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 ?o 22 Vehicle Type � Y-,.I L Q �_ Color ( I otC , Registration# License# `-I u C0 S Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color. Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Icelant roduce 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: ❑ 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, 2235,2237) ❑ 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 ❑ 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 SPWOF ❑ Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility El CIA Landfill /+�ENr El Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of Units) ElFarm/Ranch ® MEDICAL WASTE PROGRAM(4500) ❑ Primary Care El Acute Care ❑ Skilled Nursing El Large Generator El Small Generator 11LimPd�Qaa AI&2023 ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑W jWNk rs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form FIEEWRONA4 COUI 7Y EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM DEPARTMENT 0 CONTACT PERSON �7 Day Ph Night Ph PROGRAM ELEMENT FEE Z- T ❑ Surcharge FEE ❑ Other FEE INSPECT R# �5 PERMIT VALID �-� 1 2 S to � 2 3t ^ Z 3 1:1 Food Handler 1:11AMO NT PAID Date O INVOICE# h V1 611 REVIEWED BY �� ACCOUNTING OFFICE / Date J �-3 1231334 �+I��f2�^ U �1n� � -- I� __, M�(I IASTERFILE ECO� INFORM TON. N 1%�/�J 45d -_ uly"