Laserfiche WebLink
a <br /> SA:r JOAQUIN COLUL TY .L 'IRONNNENTAL HEALTH DIVE. S <br /> NLASTERFILE RECORD INFOR:tiLATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Pro and New Facility <br /> Facility LD Program Record ED <br /> Facility Address IODI W s-�r CV 'l ltX StYeeP- <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 C <br /> ❑ Commissary Cl Dry 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 /> Cl .1y[obile Food Vehicle---Make Vehicle Type Color <br /> Registration# License T Sticker;;* r <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration T License# Sticker T <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 ❑ Condi6onally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ;ABOVEGROUND 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 /> ❑ HoteViti[otel-------Number of Units El Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emplovee Housi relLabor 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 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 /> `lumber of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds C3 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 Capacity Vehicle R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C1 Transfer Station C1 Ag/Cannery Waste Site C3 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 /> C3 Primary Care 11 Acute Care ❑ Skilled Nursing ❑ Large Generator C1 Small Generator C3 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 p Day Ph Night Ph <br /> PROGRAM ELEMENT ,-3qQ FEE ❑ Surcharge FEE ❑ Other FEE <br /> el on- <br /> LVSPECPOR n PERmrT VALID to ❑ Food Handler_ <br /> ❑ Check R Amon,-r PAID Date INVOICE R <br /> C3 Cash RE`/mvED By ACCOCMING OFFICE Date <br /> EH 0069 PrN-K FOR-M.doc Rev.07/07199 <br />