Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DIVISION <br /> IMASTERFILE RECORD Ii tFORNLAMON FORNI(EH 00 69) <br /> New EH Pro am at Existing Facility ❑ <br /> New EH Pro m aand New Facility <br /> Facili ID Program Record ID "d <br /> Facility Address —7 c <br /> (Please Check the appropriate description and specify siie•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: Yes ❑ No ❑ <br /> El Restaurant: Seating CapacitySquare ga <br /> C1 Commissary C1 Dry storage only C1 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Color <br /> C1 Mobile Food Vehicle---Make Vehicle Type Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> C3 Mobile Food Prep Unit—Make Sticker# <br /> Registration# License# <br /> to El Ice Plant <br /> C1 Temporary Food Facility--Dates of operation from C1 Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000 <br /> C] Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) F) I <br /> ',C-Hazardous Waste Generator---------------------— <br /> Tons Generated Per Year <br /> ly Exempt <br /> Ti�red Permitting Facility C1 Conditionally Rue Fixed Unituthorized ❑ Permit By_lRu e Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C1 HoteVivlotel-------Number of Units <br /> Employee Housing(2700)Use Employee Hourin/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental,assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ElNPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site 1:1RWQCB Cleanup Site C1 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility Cl Pool 11 Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) 0 permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle#_— <br /> ❑ Pumper Vehicle—Registration# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash e/Ash Site <br /> 1:1 Landfill C1 Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> C3Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> Cl Primary Care C1 Acute Care El Skilled Nursing ❑ Large Generator C] Small Generator C1 Limited Hauler <br /> ❑ Common Storage Facility --❑ '-- 10 ❑ l 1 -60—13>60 generators <br /> C1 Transfer Station ❑ Veterinary Clinic b <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHO69 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> �='l Li `FEE ❑ Surcharge FEE ❑ Other FEE <br /> PROGRA.,Nt ELENIENT '� ❑ Food Handler�� <br /> INSPECTOR# I, PERMIT VALID to i <br /> ❑ Check>* <br /> AMOUNT PAID Date INVOICE# ! <br /> > Date 61,11 <br /> i <br /> C1 Cash REviEWED BY ACCOUNrtNG OFFICE ` <br /> Rev.07/07199 <br /> Fu nw)P[NK FORM.doc <br />