BILLING/PERMITS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ID I� S37L•�w R YIWENT CE QED Facility Address 9210 Thornton Ave., Stockton CA 95209 SAN OA J 3 2021 (Please check the appropriate description and specify size, number of units and Pertinent information.) ENVOIRON 1N COUNTy FOOD PROGRAM (1600) HEALTH DEp RTT��TA.� ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES LJ' N& ❑ ❑ 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) ❑ Grade A Dairy ❑ Grade B Dalry ❑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 Housina/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑UST -CAP Site ❑Local HW Cleanup Site ❑ NPL/SEP RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ TATTOO. BODY PIERCING, ❑Spa ❑Out oP Service Pool/Spa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) l'7 Body Art Practitioner Reg (4 110) ❑Mechanical DSPS Notification (4115) ❑B0 Art Facility -Single Use (4120) ❑ Body Art Facility-Sterillzatlon (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body 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_ TATTOO. BODY PIERCING, ❑Spa ❑Out oP Service Pool/Spa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) l'7 Body Art Practitioner Reg (4 110) ❑Mechanical DSPS Notification (4115) ❑B0 Art Facility -Single Use (4120) ❑ Body Art Facility-Sterillzatlon (4121) ❑ Body Art Temp Event Co-ord (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/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles Por 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 112 - 10 ❑ 11 - 60 ❑ > 60 generators (4600) Use PWS EHD 46-02-003 Blue Application Form PROGRAM ELEMENT � i 1 O FEE '� I ❑ SUn INSPECTOR # 9 S 3 {� PERMIT VALID /0 j t0 11Check # /j,5 A., AMOUNT PAID 1 / •a(� Date _ 1:1Cash REVIEWED BY ACCOUNTING OFFICE 32-034 1/23/13 •4 13317 775 1 /2 A*1Mt1pw 51'rYIS 20L7'59012, ❑ Other FEE _ ❑ Food Handler INVOICE # Date //737F)