BILLING - Laserfiche WebLink

Home Browse Search

F. CI Other FEE A TERFILE RE ORD INFORMATION PINK El Surch to I Date ACCOUNTING OFFICE El Food Handler INvoicE# ate q SAN'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facilit &Jew EH Pr grama:11 New Faci it Facility ID rif-,-1,1-7 2,6 -5 Program Record ID il _ c-13/.0 Facility Address //0 /14 l, i porkd, st- Qs7--Der# 7s-D4;--- (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 0 No CI Commissary El Dry storage only 0 with Food Preparation OVending Machines Number of Units Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # 1-±"VIK Sticker # 0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from DAIRY PROGRAM (2000) El Grade A Dairy CUPA 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit El Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility Hazardous Waste Generator (2200) >-Tons Generated Per Year Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI 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) Cl Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) CI Environmental Assessment CI UST-CAP Site D Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-MM Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp EIRE,C0 LIQUID WASTE PROGRAM (4200) El Pumper VehicleRegistration # License # Capacity Pumper Yard 0 Package Treatment Plant SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station El Ag/Canner CI Waste Tire Facility 0 Compost Facility 0 Process/R Refuse Vehicles (# of units) El Dumpsters MEDICAL WASTE PROGRAM (4500) to CI CFO 0A0B 0 Out of Service Pool/Spa 0 Natural Bathing Area CI Kennel ty (4131) SE§61§4 #2023 0 Chemical Toilets ----Number of Units SAN JOACAlt*GQ/A171— ENVIRONMENTAL y Waste Site ElourticeropmENT ecycle Facility CI CIA Landfill Site >20 CU yd (# of Units) CI Farm/Ranch Cleanup Site Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 CI 11 - 60 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form E ERG §§14) CY NOTIFICATION FOR THIS FACILITY ,t,ND/OR PROGRAM CONTACT PERSON )1 IV lQ Yan7Airrt4/2. Day Ph "Lecido(it i"-)Lto Night Ph 2660 0)_11-12-3,0 PROGRAM ELEMENT I 3 FEE INSPECTOR # 61&,a c? PERMIT VALID CI Check # V 1,54" AMOUNT PAID CI Cash REVIEWED BY 4182-3021-30 34 4t. 1, (70 6 3 ts., /