BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTO DEPARTMENT MASTERFILE RECORD INFORMATION RM ❑ New EH Program at Existing Facility New EH Program and New Facility Facili ID uo 4, L Program Record ID Facility Address_'5b`- C . l-Od i 14Ve, l ccki Ca q6 (Please check the appropriate description and specify size,number of units and pertinent information.) OOD PR (1600) estaurant: Seating Capacity Square Footage Food Handlers Course required: YEs�A No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending MachmesNumber 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) ❑ 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 HHVV(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300)Use USIA and 9forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700)Use Employee HOUsinalLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local 14W Cleanup Site ❑ NPLISEP 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 Coord(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 ❑ Sludge/A �r•s ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Lam ❑ Refuse Vehicles to of units) ❑ Dumpsters>20 cu yd I#of unite) ❑ FarmlRapcph�Cles MEDICAL WASTE PROGRAM(4500) JUiy ?? w ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generato$.4g1 Iteo Halt' ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60H (g)y�rators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-01-003 Blue Application Form rNDFp VOO 7)" GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 'IRr,HE4 EM R CONTACT PERSON 016 Day Ph D' 3 Night Ph Jvr PROGRAM ELEMENT FEE 11 ❑ Surchar e F E ❑ Other FEE INSPECTOR# PERMIT VALID t0 ❑ Food Handler Check# ff�AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 6 Z 48-02-034 MASTERFILE RE R INFORMATION PINK 1l23)13