Laserfiche WebLink
R e9 T Al <br /> f <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> 9A �l : S <br /> hIASTERFILE RECORD INFORMATION FORM A S /A/ <br /> New El I Program at Existing Facility ❑New EIl Program and Nei),Facility <br /> roraRecord Facilif ID <br /> FacilityAddress 5 l5 V T`�/✓ G <br /> (Please Ceck the appropriate description and specify size'number of units and pertinent information.) K1G <br /> FOOD PROGRAM(1600) ��/�'ry <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending,Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) ro <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS INVASTE PROGRAM(2200) I <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> "ered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit 3 mit <br /> Per -By-Rule Household hazardous Waste <br /> GB <br /> OVEGI;OUND STORAGE TANK FACILITY(AST)(2390) Number of AS <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B orms <br /> IiOUSING PROGRAM(2400) <br /> ❑ Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ifousinp/fabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EnvironmentaI Assessment ❑UST-CAP Site ❑ Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IiW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 1:1 Landfill El Transfer Station 11 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,Laadfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60----❑>60 generators <br /> PUI3LIC WATER SYSTEM PROGRAM(4600) Use Pff'S EMD 4642-003 Rine Application Form <br /> r1EMERGENCY NOTIFICATION FOR This F ILITY ANDIOR I R GRAM <br /> CONTACT PERSON r>1_7)q KL' G Day P �� '' l�i2 t Ph <br /> PROGRAM ELEMENT Z 75 i FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# / 9 / PERMIT VALID to ❑ Food Ilandler <br /> ❑ Check# AmOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICL Date <br />