BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN. COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility []New EH Pro ram and New Facility RE )WENT Facility ID cov Program Re ord ID /�D 7� CEIVED Facility Address 3422 U). {tQMn9 r In s100<f y i CA gSZI Gj APR 01 2022 (Please check the appropriate description and specify size, number of units and pertinent Information.) SANJOAQUIN COU FOOD PROGRAM (1600)H EWIRONMENTAL TY ElRestaurant: Seating Capacity Square Footage Food Handlers Course required: YES,,9EWSIDENT ❑ 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 # Slicker # ❑ 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 ❑ ❑ Hazardous Waste Generator (2200)--- ....... >-Tons Generated Per Year El Tiered Permitting Facility -------> EI CA (2232) 11 CE (2233, 22344 2235, 2237) 11 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 1:1 Underground Storage Tank Program (UST) (2300) Use UST A and B forms El Other CUPA Program Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housina/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 _ 11 Pool ❑Spa VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ElTransfer Station El Veterinary Clinic 1:1 Common Storage Facility El2 - 10 L111 -60 El> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-024 Body Art Practitioner Re9% 1 ❑Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) 11Body Art Facility -Sterilization (4121) ElBody Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 11Pumper Vehicle Registration # License # Capacity Vehicle # [J Pumper Yard El Package Treatment Plant L1 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) 11Landfill ElTransfer Station EIAg/Cannery Waste Site ElSludge/Ash Site EJWaste Tire Facility ElCompost Facility ElProcess/Recycle Facility ElCIA Landfill Site 11Refuse Vehicles RofUnits) ❑ Dumpsters> 20 cu yd (#of units) L1Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) 11Primary Care ElAcute Care ❑ Skilled Nursing ❑ Large Generator ElSmall Generator ElLimited Hauler CONTACT Day Ph PROGRAM ELEMENT. VIII n FEE � R ❑ SI INSPECTOR# 98 PERMIT VALID � 7Z_ to ❑ Check# AMOUNT PAID �•7i6 Date ❑ Cash REVIEWED BY ACCOUNTING OFFICE light Ph ❑Other FEE ❑Food Handier ICE , �` INVOICE #477 03 Date 2..�?-- MASTERFILE RECORD INFORMATION 1/23/13 03 Blue Application Form CONTACT Day Ph PROGRAM ELEMENT. VIII n FEE � R ❑ SI INSPECTOR# 98 PERMIT VALID � 7Z_ to ❑ Check# AMOUNT PAID �•7i6 Date ❑ Cash REVIEWED BY ACCOUNTING OFFICE light Ph ❑Other FEE ❑Food Handier ICE , �` INVOICE #477 03 Date 2..�?-- MASTERFILE RECORD INFORMATION 1/23/13