Laserfiche WebLink
SAN JOAQUIN COTTLNTYOVIRONNLENT.0 HEALTH D,M0N <br /> NLASTERFILE RECORD LYFORVL-kTIOiY FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Pro d ew <br /> Facility ID A co i Program Record ID yJ119 , <br /> Facility Address 1566N . MA I h 5t-, MGI dcCo . <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 ❑ <br /> ❑ Commissary ❑ 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 /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration" License" Sricker" <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration" License" Sticker" <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 ❑ irlilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) alz (jIJ� (-ng69 <br /> HAZARDOUS WASTE PROGRAM(2200) ..11 <br /> ❑ Hazardous Waste Generator-----------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Condidonally Authorized(CA) ❑ ConditionaUy Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE THINK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE T VNK(UST)PROGRAM(2300)Use USTA and 8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/i•lotel----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee NousinalLabor Camo Application 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 /> ❑ .Abandoned HW Site ❑ Pon-NPL/SEP 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 ofbirds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ PumperVehicle—Registration? License" Capacity Vehicle" <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill Cl TrausferStadon ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility Cl Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Raach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑Sm211 Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- IO—❑ 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 /> PROGRASt ELEMENT 2A61 FEE ❑ Surcharge FEE ❑ Other FEE <br /> DwECTOR" PERMrr VALID to ❑Food Handler_ <br /> ❑ Check" AMOUNT PAID Date INVOICE" <br /> ❑ Cash REV[EWEDBY 13 DD ACCgtmnNGOFFICE Date <br /> EH 0069 PINK FORM.doc 4qrRev.07/07199 <br />