Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONA1,ENTAL HEALTH DEPARTMENT <br /> MASTERFIL.E RECORD INFORMATION FORIA <br /> ❑New Eli Program at Existing Facility e-w Eli Program and New Facility <br /> Facility ID l k-, Pro ram Record I <br /> facility A.ddresS _ q5 AAA e� Ay c, _ o c,�_to A IS Zi 5 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.} <br /> FOOD I'ItOGRAdFt(1600) <br /> F1 Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs 11 No <br /> ❑ Commissary ❑ Drystorage 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# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Piant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIA2iARDOUS WASTE PROGRAM(22N)' i <br /> ❑hazardous Waste Generator..— Tons Generated Per Year ❑ Recycle I 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 Fined 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 USIA and B forms <br /> ROUSING PROGRAM(2400) <br /> ❑ Ilotel/1ltotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use rmp(oyeegausing7Eabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROV3000) <br /> 11 Environmental Assessment ❑ UST-CAI'Site El Local IIIV Cleanup Site, ElNPL/SEP Cleanup Site El UIC Site <br /> ❑ Abandoned IiiV Site ❑ non-NPIJSEP Cleanup Site ❑R`VQCB Cleanup Site ❑ NVater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ElPoultry Farms Maximum number of birds Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration ff License# Capacity Vehicle ft <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 /> ❑Defuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--11 2- 10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use P[VS.EFID 46-02-003 TslueApplica(ion Fomi <br /> EMERGENCY 140TIFICATION FOR THis FACILITY ANDIOR PROGRAM <br /> CONTACTPERSON Day Ph Night Ph _ <br /> — 1 7�, i <br /> I'ROGIL41RIELE111ENT "'IW FEE 11Surcharge FEE ❑ OtberFEE _ <br /> INSPFCTOR# ate PERMITVALID to ❑ Food Handler_ <br /> C.1 Chccl:s, _ �hlourrr P-,) _ Date 11NOICE f€ --�- /.---- <br /> p Cash I �'IE�'lF.DBY vE 31 ��_ ACCOUNTING OFFICE _ _ _ Date 7 <br />