BILLING/PERMITS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ID ❑New EH Program and New ltRM Facility Address4 IN, School street (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (16001 RAR 29 2022 cE QED SqN o ENVIRp UIN COUN LTH ry p PART4AL 11PA Restaurant: 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, 22350 2237) ❑ PER (2231) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number ofASTs ❑ 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 HousfnWLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment 11 UST -CAP Site [I Local Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑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 (4121) 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, 22350 2237) ❑ PER (2231) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number ofASTs ❑ 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 HousfnWLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment 11 UST -CAP Site [I Local RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area (4100) ❑ Kennel ■ Body Art Practitioner Reg (4110) ❑Mechanical ❑ DSPS 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area (4100) ❑ Kennel ■ Body Art Practitioner Reg (4110) ❑Mechanical ❑ DSPS Nocation (4115) ❑Body AglCannery Waste Site Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body Dumpsters > 20 cu yd (#of units) Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License # ❑ Package Treatment Plant Capacity Vehicle# 1:1 Pumper Yard ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM PUBLIC (4400) ❑ SI INSPECTOR# PERMIT VALID ❑ Landfill 11 Trans Station ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (#of 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 112 - 10 ❑ 11 -60 ❑ > 60 generators WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Farm CONTACT PROGRAM ELEMENT rI 11 O FEE 11 Cash /( ❑ SI INSPECTOR# PERMIT VALID 3Z ZZ t0, ❑ Check # .Se`- AMOUNT PAID Z*' CND Date REVIEWED BY ACCOUNTING OFFICE Ph - ❑Other FEE _ _ ❑Food H�J a7ndler _ INVOICE# � Date 'Y///; 48-02-034 _MASTERFILE RECORdINF 1!23/13 /�Q n'YJY-//I