BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COIRNTY rIRONN1ENTAL HEALTH DIVI d ,NLASTERFILE RECORD L`IFORNL-kTION FORM(EH 00 69) )RDNe-EH Program at Existing Facility ❑New EH Program and New Facility Facility ID a Program Record ID Facility Address A5Y43 t l. Nyy VV q4q (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ :Mobile Food Vehicle----Make Vehicle Type Color Registration R License R Sticker ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration T License# Sticker ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event - Dares of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ 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 UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Acplicarion Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site ❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediatiou Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility C1 Pool El Spa C1 Out of Service Pool/Spa C3 Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds C1 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) El Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) C3 Pumper Vehicle—Registration T License K Capacity Vehicle T ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh 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 C3 Skilled Nursing C1 Large Generator C1 Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Stora;e Facility —❑ 2- 10 ❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRA,Nt ELEMENT 23 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date 72 INVOICE R ❑ Cash REVIE VED BY Z `� (� ACCOUNTING OFFICE ` Date Rev.07/07x99 EH 0069 PCNK FOR.�I.doc