BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facili ❑New EH Pro ram and New Facility Facili ID FAT-D 2-(' Program Record ID 6 Z Facility Address 15 S\- (_ CA q S�Z > (Please check the appropriate description and specify siJ number of units and Pertinent information.) FOOD PROGRAM It 600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ Commissary ❑ Dry storage only pZZwith 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 At 11Mobile 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) ❑ PER 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 ❑ NPL/SEP 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 Poollspa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel PAYMENT TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) - RECEIVED ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single UseM;P)1 7 2022 ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) r..IcnumN CouN rY Ia'ARUNL4MfLL ❑ Pumper Vehicle Registration# License# Capacity Vehicle#Ir ALTI11JcrnnrtaeN1 ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units 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 r�,1 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM "" CONTACT PERSON C t- / \ t` Day Ph Z.oct Z;Z-g4US- Night Ph Lbcj _S f1 t-(N,57 PROGRAM ELEMENT FEE ❑ Surchar F ❑ Other FEE INSPECTOR#� PERMrr VAUD LZ to 0 2 ❑ Food Handler ❑ Check a AMouNr Pao '� Date D / Z 2— NVOICE ❑ Cash REVIEWED BY ACgCOUNTING OFFICE Date{0lY IQ 4"2 15 I y `9 5-S3 MASTERFIE RECORD INFORMATION PINK (J��/✓l v�S ��liLtn.� +0 6.t- -