BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RFILE RECORD INFO ❑ New EH Program at Existing Facility ❑New EH Program and New Facilit Facility ID �Q�Z%5 �� Proaram Record ID kos$ Lg)-� Facility Address ip1,&2 fA&IFIL AVFNUf, , 61-oc rITIv , (,A 015207 (Please check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM (1600) ,Restaurant: Seating Capacity -T-1 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 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: ❑ 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) ❑ PER (223 1) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA 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 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 _ ❑ 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 p� ❑ Sludge/A M1 nwt,N ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Land- 11 Refuse Vehicles I#ot units) ❑ Dumpsters > 20 cu yd (u of Units) ❑Farm/R ch Cle 1'/�•Cw� MEDICAL WASTE PROGRAM (4500) MAR O ss ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generatorlil� ited Ha43 ❑ Transfer Station 11 Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 - 60 �N9j Ilte _ uNrJY PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form ft7k�1QFniV \,! EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM T CONTACT PERSON ]A O NY (/At C2LgE, nULkiDA Day Ph!j, - i y0- (eBiDg Night PN- Nti0-b?? I PROGRAMELEMENT FEE INSPECTOR# PERMITVAL ❑ 4heck# AMOUNT PAID REVIEWED BY ❑ Surcharge FEE ❑ Other FEE to 3 --,:5 - 2 H ❑ Food Handler Date ACCOUNTING OFFICE INVOICE # Date 4a-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13vI,14 Yl•!/✓1J