BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility jidew EH Program and New Facility Facility ID Program Record ID (ZDV $45 Facility Address' Z 2 T t-y IS .f- (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 Vehicle Type Color Registration# License# Sticker# ,0 Mobile Food Prep Unit--Makeg100( ep h {.� -4-oVehicle Type Color ` Registration# License# Sticker# �'J ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Prod ecu 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 t)Qj TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ppAT CC NT ❑ Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) El Body Art Facility-R, ECEJ ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Ev&�S Mopil F ' y(4131) LIQUID WASTE PROGRAM(4200) I�Ip�r I / ❑ Pumper Vehicle Registration# License# Capacity SAN ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number A W RONMENTAL SOLID WASTE PROGRAM(4400) HEALTH DEPARTMENT ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery 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 ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EmEWW NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON � Day Ph Night Ph I57 y �✓�Z PROGRAM ELEMENT1. r_ )SS FEE1-2 ❑ Surcharge EE ❑ Other FEE INSPECTOR# PERMITVALIDto '`—M Z ❑ Food Handler ❑ Check# \/GS _ AMOUNT PAID Date L3 INVOICE$� g ❑ Cash REVIEWED BY / I� ACCOUNTING OFFICE Date S 48- 8 3 1934 �(� 2 -/ I r MASTERFILE RECOR INFORMATION PINK