Laserfiche WebLink
<br />to <br /> Milk Dispenser—Number of Containers in Multi-Head Unit <br /> UST-CAP Site <br /> Spa Natural Bathing Area <br />O Kennel <br /> Permanent Cosmetics (4122) <br /> 11 - 60 <br />CONTACT PERSON <br />48-02-034 <br />10/6/2003 <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd -—Number of Units <br /> Vehicle # <br />•Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> Limited Hauler <br /> > 60 generators <br /> Ice Plant <br /> Produce Stand <br /> License # <br /> Package Treatment Plant <br /> UIC Site <br /> Water Quality Remediation Site <br /> Grade A Dairy Grade B Dairy <br />CURA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator----- <br /> CRT Offsite Handlers (2218) <br />Tiered Permitting Facility----------------- <br /> Out of Service Pool/Spa <br /> to <br /> Capacity _ <br /> Chemical Toilets <br />Square Footage Food Handlers Course required: Yes No pf <br /> with Food Preparation Vending Machines —Number of Units' <br /> O with Meat Market only O Multiple Departments O Prepackaged Goods Only <br /> Vehicle Type Color <br /> License # Sticker # <br /> Vehicle Type Color <br /> License # Sticker # <br /> Surcharge Fee <br />_ to <br />Date ' <br />Accounting Office <br />JAN 1 3 2005 <br />SAN JOAQUIN COUNTY <br />environmental <br />health departmentFacility Address /C>.2lc> bv1-S,'T~Gc^rv^ <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />O Restaurant: Seating Capacity <br />O Commissary Dry storage only <br /> Retail Market -—Square footage <br /> Mobile Food Vehicle----Make <br />Registration # <br /> Mobile Food Prep Unit—Make <br />Registration # <br /> Temporary Food Facility---Dates of operation from____ <br />pCspecial Event —Dates of operation from '-f-f pS <br />DAIRY PROGRAM (2000) <br />pAYMt^’ RECEIVED <br />Fee _ <br />Permit Valid <br />Amount Paid <br />Reviewed by O 3 2-/ <br />SAN JOAQUIN COUNTY EN RONMENTAL HEALTH DEPART, 2NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility _________________ ^New EH Program and New Facility <br />Facility ID A Program Record ID <br />Facility Address /O2x> <br />•Tons Generated Per Year Recycle / Exempt System (2299) <br /> Silver Only (2222) Appliance Recyclers (2217) <br /> Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Fixed Unit Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br /> Hotel/Motel------Number of Units D Jail or Exempt Institution-------Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30QO) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Pool <br />VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> Tattooing (4121) Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper Vehicle—Registration # <br />□ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />O Landfill O Transfer Station <br /> Waste Tire Facility O Compost Facility <br />O Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />O Acute Care <br />O Veterinary Clinic <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator <br /> Transfer Station Veterinary Clinic O Common Storage Facility----O 2-10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />f-f Day Ph ^73 -2^3(3 Night Ph <br />Program Element / 6 . ‘y Fee ‘y 3 - o p_______ Surcharge Fee___________ other Fee <br />Inspector # S S <2- / Permit Valid U (o to □ Food Handler <br /> Check # Amount Paid Date Invoice # 7^ <br /> Cash Reviewed by O 3 2-/ Accounting Office Date ![3!cS <br />Masterfile Record Pink