Laserfiche WebLink
S�� JOAQUIN COTYNTY RON11ENTAL HEALTH DIVI N <br /> L-�STERFELE RECOF LtiFOR -kTIOr FORA(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility LD �oc%C% �L'�Ua Program Record ID o A ?J <br /> Facility Address I�x�1 V . ,���C T( -)Y-Lc � ocl_cl , 'R Lp0►moi <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: YFs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Nrachines—Number of Units <br /> ❑ Retail Market—Square footage Cl with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ ;Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration R License T Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License T Sticker <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operarion 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 117DZ�_) " ,IIS <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Uait ❑ Perrnit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—dumber of AST <br /> UrDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use USTA end B forms <br /> HOUSING PROGRAM(2400) <br /> Cl Hotel/Motel-----Number of Ur,is ❑ Jailor Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emplovee HousbrzlLahor Camp ADolication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ oon-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 Pool El Spa <br /> C1 out of Service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4-000) <br /> El Poultry Farm ;Maximum number of birds Cl Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 ❑ Body Piercing(4120) C3 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> Cl Pumper Vehicle—Registrarion T License R Capaciry Vehicle R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site El Sludge/Ash Site <br /> ❑ Waste Tire Faciliry ❑ 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 /> Cl Primary Care 1-1AcuteCare C3 Skilled Nursing C1La Large Generator [3 Small Generator C1 Limited Hauler <br /> C1 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility — <br /> ❑ 2- 10 ❑ It -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHOlI69 Blue ApplicarioR Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT G-_�_ FEE C1 Surcharge FEE ❑ Other FEE <br /> L,4SPECTOR T PERtitrr VALID to ❑ Food Handler <br /> ❑ Check# AmoG,,N-r PAED Date INVOICE m <br /> ❑ cuh RavtEtvaD BY r� `� ()C: Accotrrr4*e OFFICE Date (P p <br /> "Rev.071071'99 <br /> EH M69 Prrn FOR.M.Coc <br />