Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIROr-Ni1ENTAL HEALTH DIVISION <br /> NLASTERFFLE RECORD LNFORtiL-kTTON FORM(EH 00 69) <br /> ew EH Pro; at Existing Faac/iliity ❑New EH Pro am and New Facility <br /> Facility ID At CDQq Program Record ED �� (� �� <br /> Facility Address NeANtDn QWd <br /> (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 C1 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending iVlachines-Number of Units <br /> ❑ Retail ylarket----Square footage ❑ with Nfeat Market only ❑ Multiple Departments Cl Prepackaged Good&Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration R License T Sticker <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration T License# Sticker <br /> ❑ Temporary Food Facility--Dans ofoperation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> R AZARDOUS WASTE PROGR_-01(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 /> NABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> U`iDERGROU`ND STORAGE TANK(UST) PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUNlotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HSV Cleanup Site ❑ NPLjSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned K:V 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 11 spa C1 Out of Service PooUSpa 1:1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds C1 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 T License n Capacity Vehicle T <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ElLaodfill C1 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CLA 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 El Skilled Nursing C1La Large Generator C3 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 PERSON Day Ph Night Ph <br /> PROGR,,m ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR PER 1717 VALID to ❑ Food Handler__ <br /> ❑ Check R A-MOttNT PAM Date INVOICE R <br /> C1 Cash REVIEWED BY I-Zl-2Lrop ACCOUNTINGO'MCE ✓_1' Date <br /> Z2 20 <br /> Rev.07/07/99 <br /> EH 0069 PCI1K FORM.doc <br />