BILLING - Laserfiche WebLink

Home Browse Search

SAN•JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION LJ New EH Program at Existing Facility ew EH Program and New Facilit Facility ID 072(�1�76, Proaram Record ID Crt't" 'T% Facility Address (�2 ( i S _So( qr, lr�)i.lr'1 ��' St 10%yi CIS 2q0 (Please check the appropriate description and specify size, number 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 ❑ Mail Market ---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only 12 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 ❑ 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 chemicals: ❑ CalARP Program ❑ 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) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ 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 INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ■. 11 Pumper Vehicle Registration # License # Capacity PAYMENT ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---- NumberRECEAtF11 SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site 1MRdge54QQjp1[te ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ��1 CIA Landfill ❑ Refuse Vehicles (#of Units) ❑ Dumpsters> 20 cu yd (# of units) y`MEtNJtV�I Teanup Site MEDICAL WASTE PROGRAM (4500) HEALTH DEPARTMENT ❑ 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 PWS EHD 46-02-003 Blue Application Form CONTACT PERSON Day Ph («21W) r10 07Night Ph PROGRAM ELEMENTJf /t ) -/ FEE C21 ❑ Surchar e F E ❑ Other FEE INSPECTOR At PERMITVALIDS t0 I .' ElFood Handler ❑ Check # r AMOUNT PAID 171Date s INVOICE # ❑ Cash REVIEWED 6Y ACCOUNTING OFFICEdZL Date ff 48-02-034CORP 1/23/13 r1 .7 /1 yA I 4 -I / I MASTERFILE RECORD FORMATION PINK