Laserfiche WebLink
-6 <br />SAN JOAQUIN COUNT)L iVIRON't IENTAL HEALTH DIVi.._JN <br />NIASTERFILE RECORD L 1FORNLaTION FORM (EH 00 69 <br />❑ New EH Program at Existing Facility ❑New EH Prograaand New Fgcility <br />Facility ID Program Record ED � <br />Facility Address ljo t)& J • [".55� %j j'L di -1 Y0 <br />(Please Check the appropriate description and specify size, number of units and peri <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capaciry Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle -----Make Vehicle Type _ <br />Registration # License # _ <br />❑ Mobile Food Prep Unit --Make Vehicle Type — <br />Registration # License # <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event - Dates of operation from to_ <br />DAIRY PROGRAM (2000) <br />CkWfW-/- <br />No-p <br />ATUN mlb <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <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-4�-Rule Household Hazardous Waste <br />XU"4AERGROUND <br />BOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST_ <br />STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ HoteUMotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Fmployee Housing (2700) Use Employee HousinglLahor Camp 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 PooWSpas 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 # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4-300) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CW 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 ❑ 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 />CONTACT PERSONDay Ph 5'� /0 q-7 Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />1,tSPECrOR# S PERMIT VALID to ❑Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ST ACCOtlNUNG OFFICE Date <br />EH 0069 PINK FORM.doe Rev. 07/07i99 <br />