Laserfiche WebLink
SAN JOAQUIN COUNTY EN'VIRONMEN'TAL 11EALT11 DEPARTMENT <br /> 11IASTERFILE RECORD'INFORMATION FORM <br /> WNew EH Program at Existing Facility []New EH Program and New Facility <br /> Faci[if ID E- ,l Pro ram Record ID -L)Sh ST <br /> Facility Address t),Ny)xoln 6L , <br /> (Please Check the appropriate description and specify size'number of units and pertinent information.) <br /> FOOD PROG[3ANI(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Ilan dlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑`rending 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 Plant <br /> ❑ Special Event -Dates of operation from to ❑ Produce Stand <br /> DAtRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> GUPA ❑ 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 Re-cyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exeaript(CE) <br /> ®Permit-By-Rule Fixed Unit ❑Permit-lay-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AS T <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and E farms <br /> ROUSING PROGRAM(2400) <br /> ❑ Hote"lotel Number of Units ❑ Jail or Exempt institution Number of Units <br /> Employee Housing(2700)Use Employee�TarrsinKabor Camp Applicafian Foran <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAI'Site ❑Local 111V Cleanup Site, ❑NPLISEP Cleanup Site ❑UTC Site <br /> ❑ Abandoned IIW Site ❑ non-NPIISEP Cleaaaup Site ❑R)VQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P®ol ❑ Spa ® Out of Service Poo1lSpa ❑ Natural Bathing-Area <br /> EJECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry harm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ 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 ❑ Compost Facility ❑Process(Recycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rancla Cleanup Site <br /> IAEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator [I Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P1f`S.E1TD 46-01-403 BlueApplica6cn Form <br /> EMERGENCY NOTIFICATION FOR TI{Is FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> 1,ROGF-4,mELEMENT FEE ❑ Surcharge FEE ❑ other FEE _ <br /> INSPECTOR# !i26- RA�D _ PERMITVALID to ❑ Food Handler_ <br /> 11 C'hcck f` Amourrr P.kw - _ 'Date 11N0ICE# --- <br /> ❑ <br /> Date <br /> Cash F�EVIEwEDBY AICOUNITING,OFFICE <br /> - = <br />