Laserfiche WebLink
n <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />❑ New EH Program at Existing Facility <br />BNew EH Program and New Facility <br />Facility ID t Y� D [f �C Program Record ID <br />Facility Address E CLQ r�Y�' <br />U iC�U SIC LTA L i NVLp <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />S Footage Food Handlers Course required: Yes ❑ No 110 Restaurant: Searing Capacity Square g ❑Vending Machines -Number of Units <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />El Retail Market ---Square footage ❑ with Meat Market only C] Multiple Departments ❑ Prepackaged Goods Only <br />Vehicle Type Color <br />❑ Mobile Food Vehicle ---Make License # Sticker # <br />Registration # Color <br />Vehicle Type <br />❑ Mobile Food Prep Unit -Make License # Sticker # <br />Registration # to C3 Ice Plant <br />❑ Temporary Food Facility --Dates oroperation from to C3 Produce Stand <br />❑ Special Event - Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy <br />❑ Grade B Dairy ❑ Nlilk Dispenser—Number of Containers in Multi -Head Unit <br />CUP A ❑ State Facility Surcharge (2399) t�22r1 A�Ii*pM� <br />HAZARDOUS WASTE PROGRAM (2200) Tots Generated Per Year <br />❑ Hazardous Waste Generator -------------- <br />C3 Permitting Facility O Conditionally[ A le Fixed Unit thorized CA) ❑ Permit -By Conditionally <br />a 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 GPROGRAM(2400)❑Jail or Exempt Institution —Number of Units <br />C3 Hotelliviotel-------Number of Units <br />Employee Housing (2700) Use E plover Hts'n�/L 6or Camo Avvlicatian Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br />ea <br />11Environmental Assessment � non-NPLISEP Cleas-r-CAP Site nup Site Local HW cleanup Site ❑ RWQCB Cleanup❑SitePu ❑PWater Quality Remnup Site ediation Site <br />C3Abandoned HW Site <br />RECREATIONAL HEALTH PROGRAM (3600) [I put of Service PooVSpa ❑ Natural Bathing Area <br />Number of Pools/Spas at Facility Cl Pool ❑ Spa <br />VECTOR CONTROL PROGRAM (4000) ❑ Kennel <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC oP O RA (4100) ❑ Permanent Cosmetics (4122) <br />❑ <br />❑ Tattooing (4121) y <br />LIQUID WASTE (4120) <br />PROGRAM (4200) Capacity Vehicle # <br />License # <br />❑ Pumper Vehicle -Registration # __� ❑Chemical Toilets—Number oFUnis <br />❑ Pumper Yard C3 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400)❑ SludgeJAsh Site <br />❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ CIA Landfill Site <br />❑ Landfill [3 ProcesslRecycle Facility <br />❑ Waste Tire Facility ❑ Compost Facility umber of Units C3 umber <br />Cleanup Site <br />❑ Refuse Vehicles -Number of Units ❑ Dumpsters > 20 cu yd —N <br />MEDICAL WASTE PROGRAM (4500) ❑ Large Generator El Small Generator [J Limited Hauler <br />❑ Primary Care ❑Acute Care <br />[I Skilled Nursing ❑ I I - 60 —C3> 60 generators <br />❑ Transfer Station ❑ Veterinary Clinic ❑Common Storage Facility —❑ '-- 10 ---- <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHBB60 Blue Application Farm <br />EMERGENOY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Dav Ph Night Ph — <br />CONTACT PERSON <br />P ROGI44M ELENIENT %� FEE — <br />INSPECTOR#�— PERMITVALID <br />❑ Check# <br />17-1 r,Io, <br />❑ Surcharge FEE <br />to <br />AMOUNT PAID �--- ""•• <br />REVIEWED BY ACCOUNTING OME <br />❑ Other FEE �- <br />❑ Food Handler ----- <br />INVOICE # <br />Date— <br />Rev.o7/07,99 <br />