BILLING - Laserfiche WebLink

Home Browse Search

t PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM N F k 2 5 i0a )KLNew EH Program at Existing Facility []New EH Program and New Facility SAN JOAQUIN COUNTY Aq ENVIRONMENTAL Facility ID Q O j k, Pro ram Record ID -4;?77$ ( HEALTH DEPARTMENT FacilityAddress 355 cz-oS— (Piease fleck the appropriate description and specifyLizenumber 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 ❑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 [3Special Event -Dates of operation from to 11 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 I Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑Silver Only(2222) ❑ Appliance Recyclers(2217) 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 forms HOUSING PROGRAM(2400) - ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Emplpyee7fousinp/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTR043000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local BW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned IIW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) - Number of Pools/Spas at Facility ❑P901 ❑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(4121) ❑ 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) ❑ Land611 ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑Precess/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles-Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch 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-43 2-10—❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIES FffD46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON te-O-SAt-(11 -,/'6A471' Day Ph Night Ph PROGRAM ELENIENr /, -(-'2e FEE / O'D -0 5�❑ Surcha eFEE 1:1 Other FEE INSPECTOR# � (OLI 3 ERMIT VALID �S�D u to Lt 3`-�)Q Check# AMOUNT PAID `E0( 0. ()� Date �-SD 6 INVOICE# �� Cash REVIEWED BY v 0 3�/ ACCOUNTING OFFICE Date a-,5