BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existino Facilitv []New EH Proaram and New Facility lD O Zj,,L j L Program Record lD 10 .7w f l JS U _ Facility Address 1*71-S 1,.1_ Vo:,.emi1° (1tUQ k�\it (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 (2006) ❑ 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) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel ------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-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 ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Nursing Large Generator 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) ❑ Pumper Vehicle Registration # License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) El Landfill El Trans Station L1Primary Care 11 Acute Care El Skill Capacity VeDAVM=KIT 11 Pumper Yard ❑ Chemical Toilets ----Number of Unit �v � El AglCannery 11 Waste Tire Facility 1:1 Compost Facility 11 Refuse Vehicles (#ofunits) MEDICAL WASTE PROGRAM (4500) Waste Site El Sludg��h �i� Z022 ❑ ProcesslRecycle Facility ❑ CIA L II i e ❑ Dumpslers> 20 cu yd (#of Units) El FagpWj kbLgjgE0tji ENVIRONMENTAL ❑ Small GeneratoVT�ILU&WjMg�T 10 El 11 - 60 11 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON J11r/,,QorrO Y I Day Ph X20 9) /-116—VbV � Night Ph PROGRAM ELEMENT —1 i � � FEE -U (S� ❑Surcharge FEE ❑Other FEE INSPECTOR# 01184 PERMITVALID�'7/13/ZZ to Io/30 23 ❑ Food Handler ❑ heck fl AMOUNT PAID 'f' Date V1 %D L 1i INVOICE # ash REVIEWED BY ACCOUNTINGOFFICE Date 8-02-034 MASTERFILE RE OR INFORMATION PINK 1/23/13 Nursing Large Generator ❑ Transfer Station El Veterinary Clinic ❑Common Storage Facility ❑ 2 ENVIRONMENTAL ❑ Small GeneratoVT�ILU&WjMg�T 10 El 11 - 60 11 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON J11r/,,QorrO Y I Day Ph X20 9) /-116—VbV � Night Ph PROGRAM ELEMENT —1 i � � FEE -U (S� ❑Surcharge FEE ❑Other FEE INSPECTOR# 01184 PERMITVALID�'7/13/ZZ to Io/30 23 ❑ Food Handler ❑ heck fl AMOUNT PAID 'f' Date V1 %D L 1i INVOICE # ash REVIEWED BY ACCOUNTINGOFFICE Date 8-02-034 MASTERFILE RE OR INFORMATION PINK 1/23/13