BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM flow EH Program at Existing Facility _ —� ❑New EH Program and New Facilit Facility ID Program Record ID Facility Addresses= . J r 51CLV_ 61" ,Q-1 e (Please check the appropriate description and specify size, nurnber of ur Its 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 f/_ Sticker# ElMobile Food Prep Unit—Make Vehicle TyF e Color Registration# _ License f Sticker# ❑ Temporary Food Facility—Dates of operation from_ _ to ❑ Ice Plant❑ Produce Stand ❑ Special Event—Dates of operation from to _ ❑ CFO ❑ A❑ B DAiRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemical 3: ❑ CaIARP Program la Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)—>-Tons Generated Per Year ❑ Tiered Permitting Facility -> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2803) Number of AiiTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA and El forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Fall or Exempt Institution ---Number of Units Employee Housing(2700) Use Employee Houslnq/Labor Camp AppllcaiIon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RVIQCB 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 PF�OGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notiflcatlon(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4f2l) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) 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/Cannery Waste Site El Waste Tire Facility El Compost Facility ElProcessll2ecycle Facility 92vVIamni ❑ Refuse Vehicles(N o1 Units) ❑ Dumpster>20 cu yd(#of Units) ❑ Fan-Ft agcq Gla q Site MEDICAL WASTE PROGRAM(4500) !l��E t� II ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Lar(le Generator ❑ Small Ge'IftB(tsgp �d1}) _h�P ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -6'VERDEF/>2166,�iPie-11tors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWSE*H.D 46-02-003 Blife Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTgCT PERSON — k_ Day Ph 2_G--1-Y_I S -2_3u,.S Night Ph PFiQ{3R/�Mt ELEMENT ,' _ FEE c — El Surcharge FEE 11 Other FEE OSPECTi)R# ;rte PERMIT VALID to ❑ Food Handler ❑ 'J14 MOUNT PAID' J 1 Dale INVOICE# r i ACCOUNTING OFFIC= Date -- MASTERFILE Rpr.nRn INFnRMATION PINK