BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTnIENT \^ MASTERFILE RECORD INFORMATION FORM 1~J New EH Program at istin Facility ❑New EH Program and New Facility Facilif ,ID Program Record ID FROJT 25 3 Facility Address g'Lf S� A Tic (Please Check the appropriate description and specify sizenumber of units and pertinent information") FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food handlers Course required:. YEs❑ No ❑ ❑ Commissary ❑ Dry storage only Elwith Food Preparation ❑Vending Machines—Number of Units 11Retail 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(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator---- Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑ e t y-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B om s f' HOUSING PROGRAM(2400) ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee housing(2700)Use Fmployee Housinp/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned 11W Site ❑non-NPL ISEP 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 11 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 11 Ag/Cannery Waste Site ❑ Studge/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 ❑Farmllt2uch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIES EMD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM Et�u FEE ❑ SurchargeFEE ❑ Other FEE INSPECTOR# ITVALID to ❑Food Handler ❑ Check# AmOUNT PAID Date INVOICE# ❑ Cash REvir-WED BY AccouNnNG OFFICE Date g a7 7 A. torf1P RernrA Pink