Laserfiche WebLink
J <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />i <br />VIASTERFILE RECORD L`IFORMATION FORM (EH 00 69) <br />❑ New EH Program at Existing Facility New EH Program and Crew racutry <br />Facility Address I f <br />(Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />11 Restaurant Searing CapacitySquare Footage Food Handlers Course r�uired: Yes ❑ No El <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market ---Square footage El with Meat Market only C1 Multiple Departments [I prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dates of operation from <br />Vehicle Type Color <br />License # Sticker # _ <br />Vehicle Type Color <br />• ------ u Sticker # <br />to ❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ <br />❑ Grade A Dairy ❑ Grade B Dairy Milk Dispenser—Nu/�mber of Containers in Multi -Head Unit <br />CUPA❑ State Facility Surcharge (2399)22i7 vsJ/tl�A,,— �CyG(�-�- <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 -Rule 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 PROGRAM (2400) <br />❑Jailor Exempt Institution —Number of Units <br />C1 Hotel/ vlotel------Number of Units <br />Employee Housing (2700) Use Employee Ifoushr /Labor Cama Application Form <br />SITE MITIGATION (2900) 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds — <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) 11Permanent Cosmetics (4122) <br />❑ Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br />❑ Kennel <br />LIQUID WASTE PROGRAM (4200) Vehicle # <br />❑ Pumper Vehicle—Registration # License #— Capacity <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />i <br />SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash e/Ash Site <br />❑ Landfill C1 Transfer Station 13 Ag / Cannery Waste Site g <br />❑ ProcesslRec cle Facility❑CIA Landfill Site <br />❑ Waste Tire Facility ❑Compost Facility y [I Farm/Raneh Cleanup Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters> 20 cu yd —Number of Units <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 Application Form <br />EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br />CONTACTPERSON <br />PROGRAM ELEMENT ­L rL I C FEE <br />INSPECTOR#Z I � PERMR VALID <br />❑ Check # AMOUNT PAID _ <br />❑ Cash REVIEWED BY <br />Day Ph <br />Ph <br />❑ SurchargeFEE❑ Other FEE <br />to ❑ Food Handier�� <br />Date INVOICE # _ <br />ACCOUNTING OFFICE <br />Date <br />Rev. 07107/99 <br />