Laserfiche WebLink
0 <br />SAV JOAQUINCOUNTY ENVIRONMENTAL HEALTIi DEPATZ`I LENT <br />NIASTERFILE RECORD INFOMIATION FOInT <br />New EH Program at Existing Facility ❑New Ell Program and New Facilit <br />Facility �f}�nl, �_ Program Record ID �� s-�S3�O <br />II➢ — <br />ji',lcility Address — l t'"l'h�Y� <br />(Please Check the appropriate description and specify size, <br />FOOD PROGRAM (16N) <br />of units and pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Alat ket —Square footage El with Meat Market only <br />❑ Mobile Food Vehicle ---Mahe <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event —Dates of operation from <br />Vehicle Type <br />License # _ <br />Vehicle Type <br />License # <br />to <br />Food Handlers Course required: YFS ❑ No ❑ <br />❑Vendiab Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />Color <br />Sticker # <br />Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy F1 Grade B Dairy 11 Milk Dispenser--Numbcr of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS MrASTE PROGRAh1(2200)+ <br />❑ Iiazardous 'Waste Genera tor- ---Tons Generated Per Year ❑Recycle ! Egetrapt System (2299) <br />❑ CRT Offsite Handlers (221 E) ❑ Silvcr Only (2222) _ ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility--- -- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Pert ait-By-Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK. FACILITY (AST) (2390) Numbcr of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and F forms <br />IiOUSIHG PROGRAM (2400) <br />❑ IIotcUj\Iotel Number of Units F1 Jail or Exempt Institution ---Number of Units <br />Emptoyee housing (2700) Use Frrrploye� IfousinevTabor CamE Anpficatiort Form <br />SITE MITIGATION (2800) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAI' Site ❑ Local IINV Cleanup Site. ❑ NPL(SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned IIiir Site ❑ non-NPL/SEP Cleanup Site ❑ Rii'QCB Cleanup Site ❑ iirater Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Sen'Iee Pool/Spa ❑ Natural Bathing Area <br />VECTOR Co14TROL PROGRAM (4000) <br />❑ Kennel <br />ElPoultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT CO'smETic PROGRAM (4100) <br />El Tattooing (4121) V1 Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PF OGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity Vehicle <br />❑ Pumper Yard ❑ Package Treatment Plaut- ❑ Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />te <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ CIA LandSludgehksll Site <br />iVaste Tire Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CTVRluc Landfill Site <br />❑ refuse Vehicles —Number of Units — ❑ Dumpsters > 20 cu yd —Number of Units ❑ F arm/I a nch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care El Acute Care El Skilled Nursing El Large Generator ❑Small Generator [I Limited Hauler <br />El Transfer Station El Veterinary Clinic El Common Storage Facility ---E] 7_ - 10 El 11 - 60 --- ❑ > 60 generators <br />PUBLIC. WATER SYSTEM PROGRAM (4600) Use Pif'SFHD 46-02-003 RhfcApplfcariorl Form <br />EmERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR {PROGRAM <br />CONTACTPk RSON <br />IIROGILAME,,Lt.NIENT 1—t-7 0 FrE_ <br />INSPECTOR# c Jr© PER-Nt1l-VALID <br />❑ Clr ck AMOUNT PAID <br />F1 Cash R EVIEwED BY <br />Day Ph <br />Night Ph <br />❑ Surcharge FEE ❑ Other FFE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Food Handler <br />Ir4-vroicr # _ <br />Date— ��J 51��-- <br />