Laserfiche WebLink
SAN JOAQUI_, COUNTY ENVIRONMENTAL HEALTH DIVISION <br />lL-kSTERF LE RECORD ViFORtiL-MON FOR:NI (EH 00 69) <br />�'ew EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID FA 0dC,).q 1q Program Record ID J 5�(� 4.7 <br />Facility Address x( -10 L J i1'YKLi , L /M H Y U P(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <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 R License # Sticker # <br />❑ Temporary Food Facility ---Dates of operation from to <br />❑ Special Event - Dates of operation from to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ iVlilk 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 ❑ Perrrut-B 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 />❑ HoteUNIotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee f ausinelLabor Camp Ayolication 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 Cl Pool ❑ Spa C1 Out of Service PooUSpa C3 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />C1 Poultry Farm Maximum number of birds [1 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) C1 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # <br />License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />El Landfill C1 Transfer Station ❑ Ag / Cannery Waste Site [1 SludgelAsh 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 ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care C1 Skilled Nursing 1:1 Large Generator C3 Small Generator ❑Limited Hauler <br />❑ Common Storage Facility❑ 2 - 10 -- ❑ 11 - 60 —❑ > 60 generators <br />❑ Transfer Station C1 Veterinary Clinic e — <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELE,riENT� U FEE — <br />INSPECTOR# PER.Nirr VALID <br />❑ Check k Ar O :'T PAID <br />❑ Cash REVIEWED BY a& q I � <br />EH 0069 PINK FORIM.do <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler <br />Date <br />ACCOUNTING OFFICE <br />INVOICE n <br />Date O'N <br />Rev. 07i07i99 <br />