Laserfiche WebLink
SAN JOAQUIN COUNT ;NVIRONMENTAL HEALTH DIti..40N <br /> 11 MASTERFII,E RECORD INFORMATIG�N F��RM(EH 00 69) <br /> 16 New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facili ID Proaram Record ID <br /> Facility AddressLeo <br /> � 3 \I► <br /> (Please Check the appropriate description and specify size,number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing CapacitySquare 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) <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 /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Pule 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_Lorms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee H'ousrn?/Labor Camp.Application Form <br /> SITE MITfGATION(2.900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ 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 ❑ 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 it <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag 1 Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfdl Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd --Number of Units ❑ FarnVRanch 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 --❑ 2- 10 ------❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Ajpllcation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT2 G,S -I 0 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# t^ V PERmrr vALID to ❑ Food Handier � <br /> ❑ Check# AIMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BYlr FSI ACCouNTnvG OFFICE Date <br /> EH 0069 PfNK FORM.doc <br /> Rj07l07199 <br />