Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMI ENTAL:HEALTH DIVISION <br /> MASTERFILE RECORD L`IFORNIATION FORM(EH 00 69) <br /> New EH Prorram at Existing Facility <br /> ❑New EH Pro and New Facili <br /> Facility ID FN Do ( L)L, 2Z Program Record ID PR59 <br /> Facility Address —17 S 5 tkw . `� �"` <br /> (Please Check the appropriate description and specify size•number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: Yrs❑ No ❑ <br /> ❑ Restaurant: Searing Capacity - Square Footage _❑Vending Machines-Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation <br /> El Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make License# Sticker# <br /> Registration X Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit-Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event -Dates of operation from_ <br /> to <br /> DAIRY PROGRAM(2000) <br /> C3Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> CUP A ❑ State Facility Surcharge(2399) ��G( Oil Oil.f,A' <br /> H-AZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year 2'�'y� V <br /> p4iazardous Waste Generator------ —-----Tons <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 TAI`IK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt Institution—Number of Units <br /> ❑ HotellMotel-----Number of Units <br /> Employee Housing(2100)Use£moloyre No /GAAP*Cama Aoolicnriort Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> anup Site 11RWQCB Cleanup Site C1 Water Quality Remediat(oa Site <br /> C1 Abandoned HW Site ❑ non-NPWSEP Cie <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility ❑ Pool 11 spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT OBodyPiercing <br /> e cing(4120)(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle It <br /> C1 Pumper Vehicle-Registration#* License# Ca p ty <br /> [Plant ❑ Chemical Toilets—Number of Units <br /> [3 Pumper Yard ❑ Package Treatmen <br /> � <br /> SOLID WASTE PROGRAM(4400) ❑Ag/Cannery Waste Site [3Sludge/Ash Site <br /> ❑ Landfill [3 Transfer Station Process (I CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> [I Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Numberof Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care 11 Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> � <br /> _ ❑ 1 l-60—❑>60 generators <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility _[3 - (0 <br /> lication Form <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS£90069 Blue AnoAL- <br /> EMERGENCY NOTIFICATION FORTHis FACILITY AND/OR PROGP�` <br /> Day Ph fight Ph <br /> CONTACT PERSON <br /> Surcha c E EE / ❑ Other FEE —� <br /> r13 <br /> GRA,m ELEMENT 2 2Ll FEE S— /� Jo ❑ Food Handler_r/y <br /> ECTOR# Bbl(LI PERMIT VALID �/ //��/-��/ � n p3� /ah�Q� j1,ry0ICE#heck# A,rtOIM PAID k pK� Date <br /> Dateash REVIEWED BY ACCOUNTING OFFICE Rev 07/07199 <br />