BILLING - Laserfiche WebLink

Home Browse Search

'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existing Facility ®New EH Proaram and New Facilitv I Facilitv ID r -A66 )7 S7`1 Proaram Record 1 II Facility Address 1221 Vallerand Rd, Tracy, Ca, 95376 (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 ❑ with 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 _ Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Special Event Dates of operation from to DAIRY PROGRAM (2000) Color ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite Handlers (2218) ---- -- ---- ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ------------------- El Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms 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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑ Spa TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Out of ServiceFAyMENT RECEIVED FEB 0 2 2023 Natural Bathing Area Kennel ❑ Tattooing (4121) ❑ Body Piercing (4120) SAN JdADUIRfiosmetics (4122) LIQUID WASTE PROGRAM (4200) ENVIRONMENTAL ❑ Pumper Vehicle Registration # License # CapaHfOLTH DEPARTMENT Vehicle # ❑ 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 CONTACT PERSON PROGRAM ELEMENT INSPECTOR# 4589 ❑ Check # ^' G k FEE PERMIT VALID AMOUNT PAID W, Cash REVIEWED BY - 107 ■ Sul Datee ACCOUNTING Night Ph ❑ Other FEE ❑ Food Handler INVOICE# 37S4 Date �/q/9;2 ©k �b 115SkL f'C��Gf 1 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07