BILLING - Laserfiche WebLink

Home Browse Search

Milk Dispenser-Number of Containers in Multi-Head Unit------ Grade B Dairy Program 3 Facility PBR (2231) PBR HHW (2236) Natural Bathing Area Out of Service Pool/Spa Spa Kennel Skilled Nursing Large Generator 11-60 CONTACT PERSON Program Element Inspector # Check # Cash 48-02-034 1/23/13 Ag/Cannery Waste Site Process/Recycle Facility Dumpsters > 20 cu yd (# of units) Sludge/Ash Site CIA Landfill Site Farm/Ranch Cleanup Site Number of chemicals: Program 2 Facility ■>-Tons Generated Per Year CE (2233, 2234, 2235, 2237) Number of ASTs toMt Capacity Vehicle # Chemical Toilets —Number of Units License # Package Treatment Plant SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORIVIATION FORM New EH Program at Existing Facility | Facility io~ Facility Address 20 W New EH Program and New Facility „ ______ - -- . ......... - -___— - --------------r • .---r—.. , Program Record ID J I Zip (Please check the appropriate description and specify size, number of units^and pertinentjnfqrmation.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Commissary Dry storage only Retail Market—-Square footage Mobile Food Vehicle-Make Registration # Mobile Food Prep Unit- Make Registration # Temporary Food Facility —Dates of operati^rH’rom Special Event—Dates of operation from.^ ’ 0 ^19 Square Footage Food Handlers Course required: Yes No with Food Preparation QVending Machines Number of Units--------------- ____ w/Meat Market only Multiple Departments Prepackaged Goods Only _ Vehicle Type ______ Color---------------------- - ____________ _ License # Sticker # _------------------------- ___________ Vehicle Type __________________ Color—----------------------- License #__________ Sticker #---------- ------------------ tinn from to Plant Produce Stand sa t q|7/|(|Qo CFO A B DAIRY PROGRAM (2000) Grade A Dairy CUPA Hazardous Materials Business Plan (1900) CalARP Program Program 1 Facility Hazardous Waste Generator (2200) Tiered Permitting Facility > CA (2232) Aboveground Storage Tank Facility (AST) (2800) Underground Storage Tank Program (UST) (2300) Use UST A and B forms Other CUPA Program _—------------------------------------------------------- HOUSING PROGRAM (2400) ki t|| , Hotel/Motel -—Number of Units Jail or Exempt Institution —Number of Units--------------- Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTlONCONIBgL (3000) □ Environmental Assessment □ UST-CAP Site □ Local HW Cleanup Site □ NPL/SEP Cleanup Site □ UIC Si Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility Pool VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Mechanical DSPS Notification (4115) Body Art Facility-Single Use (4120) I Body Art Temp Event Co-ord (4130) Body Art-Temp Event Mobile Facility (4131) Body Art Practitioner Reg (4110) I Body Art Facility-Sterilization (4121) LIQUID WASTE PROGRAM (4200) Pumper Vehicle Registration # Pumper Yard SOLID WASTE PROGRAM (4400) Landfill Transfer Station Waste Tire Facility Compost Facility Refuse Vehicles (» oi units) MEDICAL WASTE PROGRAM (4500) , n,- •. j u„..i„, Primary Care □ Acute Care Skilled Nursing Large Generator SmaH Generator Limited Hau er □ 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 Emergency Notification for this FACILITY and/or PROGRAM Day Ph Night Ph Fee _____________ _ LI Surcharge Fee ______ LI Other Fee------------------------ . Permit Valid" i//H~ . to _ ---------- □ Food Handler----------------- Amount Paid . Date _ ---------- Invoice# 2 ---------------- Reviewed by Accounting Office Date --------------------——.—-=------------ masterfile record information pink