Laserfiche WebLink
SAM J6,kQUIN COUNT ENVIRONMENTAL HEALTH DIV IO -10 N <br />MASTERFILE RECORD 1INFORrYL4TION FORM (EH 00 69) <br />New EH Progam at Existing Facility ❑New EH Prograrn and New Facility <br />Facility ID p o l C)13% Program Record ID <br />Facility Address Z l S Sec,tnJ�, S� . <br />(Please Check the appropriate description and specify sizes number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing CapacitySquare Footage Food Handlers Course required: YEs C1 No [I <br />1Commissary 11 Dry storage only 11 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 TM Sticker R <br />❑ Mobile Food Prep Unit—Make Vehicle Type Color <br />Registration n 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) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ----------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ PetTnit-By-Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST <br />UNDERGROUND STOPLAGE TANK (UST) PROGR_aiY1(2300) Use UST,4 and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotenlotel------Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housinz/Lahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local H`W Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br />❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water 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 _ <br />TATTOO. BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity <br />Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag /Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />❑ 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 —112 - 10 <br />❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY FOR THIS FACILITY AND/OR PROGRAM <br />INOTIFICATION <br />CONTACT PERSON __iCo �: N J T e2-/• Day Ph 3 Gl. — b Z <br />Night Ph <br />PROGRAmELENIENT 09CID FEE / ❑ Surcharge6E <br />❑ Other FEE <br />I,tseecrOR# 3 b PERMrrVALID to r <br />❑ Food Handler ------ <br />❑ Check It ALMOU` T PAID Date <br />0 <br />INVOICE.# <br />f-1 rich RFViFNVMRy ACCOUNTING OFFICE cj-'� -. <br />Date <br />EH 0069 PINK FORM"doc Rev' 07107199 <br />