Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD L 1FORIAkTION FORM(EH 00 69) <br /> few EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facili ID Proaram Record IDR / <br /> Facility Address _1100 S M& n NtAX1�'�CCL <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> El Restaurant: Seating Capacity Sq ga <br /> C1 Commissary 11 Dry storage only El with Food Preparation ❑Vending Machines—Number of Units <br /> C1 Retail Market----Square footage C1 with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C1 Mobile Food Vehicle---Make Sticker# <br /> Registration# License# <br /> Color Ty <br /> pe <br /> ❑ Mobile Food Prep Unit--Make VehicleSticker# <br /> Registration# License# <br /> ❑ <br /> to Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) S r i <br /> -E -Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Conditionally <br /> Exempt <br /> Permitting Facility pen [ ly le (CA) <br /> 0 permit-By-Rule Fixed UnitC1 Permit-ByiRue Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt Institution Number of Units <br /> ❑ Hotel/Motel------Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ClUST-CAPSite C1 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site [I UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ClPool El Spa <br /> C1 out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# <br /> ❑ Package Treatment Plant 11 Chemical Toilets--Number of Units <br /> C3 Pumper Yard g <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash e/Ash Site <br /> ❑ Landfill ❑ Transfer Station C1 Ag/Cannery Waste Site g <br /> ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> 11 Waste Tire Facility C1 Compost Facility ❑ Farm/Ranch Cleanup Site <br /> C3Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> C1 Primary Care C1 Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 1:1 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —C] 2- 10--C1 i l -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> �1 2 D 0'6U ❑ Surcharge FEE [3Other FEE <br /> PROGRAM ELEMENT Z!- FEE <br /> IySPECTOR# 0,4OLiy1 PERMIT VALID_ILI Z to 2�3 ❑ Food Handler 1 - 3 <br /> C3Check# <br /> AMOUNT PAID Date INVOICE# 1 <br /> ACCOUNrtNG OFFICE !L=�, Date <br /> ❑ Cash REVIEIVED BY Rev.07/07!99 <br /> CU(Info on.IK FARM rinr <br />