BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY _-,VIRON-MENTAL HEALTH DIVI___ NL-kSTERFILE RECORD [INFMMATION FORM (EH 00 69) +New EH Program at Existing Facility []New EH Proeram.and,New Facility Facility ID 1b%7r44f1fn_ 'm7 0% Program Record ID P91 J"J I I I Facility Addfess `572_ (Please Check the appropriate description and specify si e, FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Mobile Food Vehicle -----Make Vehicle Type _ Registration # License # ❑ Mobile Food Prep Unit --Make Vehicle Type _ Registration # I License # ❑ Temporary Food Facility ----Dates of operation from ❑ Special Event - Dates of operation from to— number of units and pertinent information.) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines —dumber of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker n 711 C3 Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) Cl Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator -----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST �— 1— 1, ocom t1w, new a UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms '_ -'og (�I I d � us<j p1 l HOUSING PROGRAM (2400) VV''��'' ❑ HoteUiviotel------- Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee HousinzlLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds C1 Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle—Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 -- ❑ 11 - 60 — C3 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM f_n _r r"r Drr)Qn%r Dav Ph Night Ph PROGRAM ELEMENTLAM FEE _ INSPECTOR # PERMIT VALID ❑ Check # AMOUNT PAID ❑ Cash REVIEWED BY EH 0069 PINK FOR-M.doc ❑ Surcharge FEE ❑ Other FEE to ❑ Food Handler Date ACCOUNTING OFFICE INVOICE Date Rev