BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COILS i--:,.i+fVIRONiNLENT-AL HEALTH DIc.,.,JN _NLASTERFILE RECORD ]ENFORNLATION FORYI(EH 00 69) New EH Program at Existing Faciliry ❑New EH Program and New Facility Facilitv ID FA D00 q q49 Program Record ID /;/�� 7� Facility Address ` l I N. 0IY' pov' F- Way , NACw),i-cCcc (Please Check the appropriate description and specify size number of units and Qerrinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending ivlachines-Number of Units ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration T License I Bricker ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration T License 9 Sticker r C1Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event - Dares of operarion from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator---------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) tor, ❑ Permit-By-Rule Fixed Unit C3Permit-By-RuleHousehold Hazardous'Waste >DA BOVEG ROUND STORAGE TANK FAC U-ITY(AST)(2390)--Number of AST UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotei/Motel----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Emplovee HousinelLahor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ UIC Site Cl 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 Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(41000) ❑ Poultry Farm—Maximum number ofbirds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Regisrrarion T Licensed Capacity Vehicle R ❑ 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-Number of Units ❑ Dumpsters>ZO cu yd—Number 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—❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEV1E`T210 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR Y PERNtrr VALID to ❑ Food Handler. ❑ Check AmoUN-r PAID Date INVOICE T ❑ Cash REV[EWEDBY -z,I-pt> ACCOtrfMGOFF[CE ., .I Date EH 0069 P[NK FORNl.doc Rev.07,107199