Laserfiche WebLink
S:-',-,N JOAQUIN COC TY __. ,rIRO`N1ENT AL HEALTH DM: N <br /> N, L.kSTERFILE RECORD E FORNL-TION FORINI(EH 00 69) <br /> New EH Proo-ram at Existing Facility [I New EH Program and New Facility <br /> Facilitv LD F:A DDD G(cog Program Record ED Pie S/5107�y <br /> Facility Address gX1 X30-Ck- �DIGC�'Ylb�1G1 �UDW <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> C1Commissary C1Dry 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 M License M Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration M License M Sticker M <br /> ❑ Temporary Food Facility--Dates of operation 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 /> 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 Cl Permit-By-Rule Household Hazardous Waste <br /> )4aBOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUitilotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use EmOovee KousinglLabor Camp 4oa/ication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl 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 Cl Spa ❑ Out of Service PooUSpa ❑ Natural Bathing area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 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 M License M Capacity Vehicle M <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C1 Transfer Station C3 Ag/Cannery Waste Site El Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ 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 /> C1 Primary Care C3 Acute Care C1 Skilled Nursing C1 Large Generator C1 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 /> PROGRAM ELEMENT Q FEE ❑ Surcha be FEE ❑ Other FEE <br /> INSPECTOR n PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br />,� ❑ Cash REVrEWED BY 1.av ACCOUNTING OFFICE 'i ' Date / o� .��j <br />�a 07/07i99 <br /> EH 0069 Pr`1K FOR.\t.doc <br />