Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />INFORMATION FORM <br />❑ New EH Proqram at Existing Facility ❑New EH Proaram and New Facility <br />ID I') o2 -S <br />Facility Address (1")1 k�" - l t-) JE 9-0 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage <br />❑ with Meat Market only <br />❑ Multiple Departments[] Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker #. <br />❑ Mobile Food Prep Unit <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br />Make <br />License # <br />to <br />to <br />Vehicle Type Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAjARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator -----------Tons Generated Per Year C ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) --- ------- -❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility -------- --- ---- ❑ Conditionally 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 />❑ Hotel/Motel----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 HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (a of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />GUN FAG I PEK51JN Uay Ph Night Ph <br />PROGRAM ELEMENT <br />1 222.0 FEE /2-13 - 0 U 11Surcharg�ee FE ElOther FEE <br />INSPECTOR # Tl�"� Ly, 'PERMIT VALID I I�) /J q to C:J ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />1:1 Cash REVIEWED BY ACCOUNTING OFFICE Date <br />i�C C�9'k �l Llr RECr 1N Nl NC-\ 200E <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />t of 5fm <br />