Laserfiche WebLink
SAN JPO:*QUIN COUNTY ENNMENTAL HEALTH DEPARTTWT <br />MASTERFILE R ORD INFORMATION FOR -NI <br />New EH Program at Existing Facility ❑Nea EH Proffram and New Facili <br />Facility ID F�} G D C) i �c Program Record ID �/����y Qbb <br />Facility Address /of Ig M0 Fal C) Vd <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: <br />Seating Capacity <br />Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary <br />❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines --Number of Units <br />❑ Retail Market <br />----Square footage <br />❑ with Meat Market onl, <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make Vehicle Type <br />Registration # License ',— <br />El <br />❑ Mobile Food Prep Unit -Make Vehicle Type <br />Registration # License <br />❑ Temporary Food Facility -----Dates of operation from to <br />❑ Special Event -- Dates of operation from to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ------------------ El 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) Num-er of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use CSTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ hotel/Nlotel------- Number of Units ❑ Jail or Exempt Institution -------Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Canip 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 ❑ non-NPL/SEP Cleanup Site ❑ RR'QCB 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 of birds ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />El Tattooing (4121) 11 Body Piercing (4120) 11 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # Capacity Vehicle # <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 El Compost Facility ElProcess/Recycle Facility El 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 />El Primary Care ❑ Acute Care El Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- El 2 - 10 ------- ❑ 11 - 60 ------ ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 BlueApplication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGKAM ELEMENT y_)L/ G FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # D Ofp O PERMIT VALID to ❑ Food Handler <br />❑ Check H AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY BIZ S (7 ACCOUNTING OFFICE Date 4"Z-66 <br />Masterfile Record Pink <br />48-02-034 <br />10/6/2003 <br />