BILLING - Laserfiche WebLink

Home Browse Search

SAN'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION ORM ❑ New EH Program at Existi'n FacilityNew EH Program and New Facility Facility ID OD/� Program Reco!]ld ID Facility Addres 321-1 t7 FA OM1 L( -N 015 W'C (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 ❑ Retail Market---Square footage ❑ w/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❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) 1:1 Grade Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP 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 Housing/Labor Camp Application 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 ❑ 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 ❑P,XPENT TATTOO. BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) RECENED ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-SingjP„��(�1221 ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event it ac lity(4131) LIQUID WASTE PROGRAM(4200) SAN JOAQUIN COUNTY ❑ Pumper Vehicle Registration# License# Capacity OA1M RTMrNT ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Ups TH D� SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters>20 cu yd (#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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMER ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON � r ri%D {1 ay Day Ph rI 23U– CI 79(PNight Ph��1� 23Q'�17 l� PROGRAM ELEMENT 1 Ob FEELID ❑ Surcha a FE ❑ Other FEE INSPECTOR# PERMIT VALID///:?-G to I / - / ❑ Food Handler ❑ Check# AMOUNT PAID C — Date Ir I INVOICE# 2 Cash REVIEWED BY ACCOUNTING OFFICE '/ Date2p Zl 482-034 MASTERFILE REbORd INFORMATION PINK 1/23/13