BILLING - Laserfiche WebLink

Home Browse Search

k SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility C6New EH Program and New Facility Facility W Program Record ID racility Address 3ti5 - (-,�e,�-z��;e� I—A. ZZj (Please Check the appropriate description and specify size•number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No ❑ ❑ Commissary11Dry storage only 11with Food Preparation ❑Vending Machines—Number of Units [:1Retail Market—Square footage ❑with 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 ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(20W) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) l ❑Hazardous Waste Generator—. —Tons Generated Per Year ❑ Recycle f Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) = ❑ Appliance Reeyclers(221 7) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B farms HOUSING PROGRAM(2400) ❑ Hote"lotel Number of Units ❑Jail or Exempt Institution Number of Units Employee housing(2700)Use Employee HousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑ 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 ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING,PERMANENT_COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag f Cannery Waste Site ❑ Sludge/Ash Site ,Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farnv auch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator D Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60—❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PH'SEfID 4642-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PItOGRAM1I F,LENIENT ll �f Lf 7� �I4EE_ ❑ Surcharge FEE . ElOther FEE INSPECTOR# tJ_ PERMIT VALID . to_ ❑ Food Handler n, Steck# khIOU T PAID I)af P, IN-VOICE 1?, VIEW."'DB`J Date --- - ...._....del.. n... ... .-..