BILLING (2) - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM El New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID fib ;?273 2 Program Record ID (Z.[5y-% �L9 Facility Address i5lt N �iuev}er (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 # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ ❑ Produce Special Event ---Dates of operation from to El CFO 1:1A 11B DAIRY PROGRAM (2000) 11 Grade A Dairy 11 Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit 11 Aboveground Storage Tank Facility (AST) (2800 Number of ASTs 11 Underground Storage Tank Program (UST) (2300) Use UST A and B forms El Other CUPA Program Program 3 Facility Stand PBR (2231) ❑PBR HHW (2236) COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program El Program 1 Facility El Program 2 Facility 11 lHazardous Waste Generator (2200) ---------->-Tons Generated Per Year 11 Tiered Permitting Facility -------> 11 CA (2232) El CE (2233, 2234, 2235, 2237) ❑ HOUSING PROGRAM (2400) ❑ HotellMotel ------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) 11 Environmental Assessment ElUST-CAP Site 1:1 Local HW Cleanup Site ElNPLISEP Cleanup Site 11UIC Site 11 Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ElRWQCB Cleanup Site El Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 11 Pool El Spa 11 Out of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farmm-------Maximum number of birds 11 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) D Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 11 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) :1 Pumper Vehicle Registration # License # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill 13 Trans Station ElAg/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility 11 Comp Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (# of units) ElDumpsters > 20 cu yd (# or units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care El Acute Care El Skilled Nursing El Large Generator ❑ Small Generator El❑ Transfer Station El Veterinary Clinic 11 Common Storage Facility El - 10 ❑ 11 - 60 qQ� PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form oto IvieD EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM AUG CONTACT PERSON PZosem^h e, Vtll�y�,c i0,1 95q 2�I(o5 Day Ph Night Ph PROGRAM ELEMENT sol 1 (n FEE � I ❑ S INSPECTOR# 997%/. ■ PERMIT VALID gZGJ t0 AMOUNT PAID J �� Date REVIEWED BY ACCOUNTING OFFICE 40 -VL -V J4 I� �� 1123/13'�`` Food Hani Other FNFEFNNN�"'N c ""'��N j ❑1��E�P ax..'�T _ 22 INVOICE# 3 Z Date !41 Z MASTERFILE RECO D INFORMATION PINK