BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility New EH Program and New Facility Program Record ID 1-1.0,5-11-n-LI / 'Facility Address -?3e, 5 c q 5./Cr-kk C'c4 q 5 2O3 (--Facility ID (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 0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units 0/Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only g Mobile Food Vehicle --Make Vehicle Type Color Registration # License # \..\\j P\\--\27\12,3 Sticker # Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CU PA 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) 0 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 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) Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper VehicleRegistration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles (# of Units) 0 Dumpsters >20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators UBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form G3 ONTACT PERSO Liao .., EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ‘. .75 Day PIVOV c't to- ?f Night Ph(269/1 I 0 — e y ?6' PROGRAM ELEMENT \\V) FEE f2-0 0 Surchar e F 0 Other FEE INSPECTOR # PERMIT VALID /J/2_ to 3( 0 Food Handler Check # r -t AMOUNT PAID 37, OD Date INvoicE # 3 Cash REVIEWED BY ACCOUNTING OFFICE Date i k, 2- 48-02-034 1/23/13 , 51 MASTERFILE REC RD IN ORMATION PINK PAYMENT RECEIVED J.Alg 1 6 2024 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT