Laserfiche WebLink
SAN JOAQUIN COUNTY E1 IRONMENTAL HEALTH DIVISIO ;; <br /> MASTERFILE RECOR: ..NFORMATION FORM EH 00 69 <br /> ew EH Pro ram at Existing Facilit ©New EH Pro ram and New Facility <br /> 1 <br /> Facility ID G Program Record ID <br /> Ni 7,e <br />� Facility Address <br /> (Please Check the appropriate description and specify size•number of units and ptrtinenfornl2tiOtl.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course <br /> e re ui�red: Yes 11 No❑ <br /> ❑ Commissary ❑ Dry storage 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 Plant <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-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> I ❑ Hazardous Waste Generator---------Tons Generated Per Year ❑ Recycle/Exempt System <br /> Tiered Permitting Facility ❑ 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)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee Housing(2700)Use Employee Housin /Labor Eamp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB 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 /> Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent <br /> Z� ` Cosmetics 4 <br /> 122) <br /> 14UID WASTE PROGRAM dSveAl-,{ Vc Cie <br /> #❑ Pumper Vehicle—Registration# � icense# Capacity <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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------011 -60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 B/ue Application Form <br /> EMERGENCY NOTIFICATION FOR TH15 FACILITY ANDIOR PROGRAM <br /> ;CONTACT PERSON rDay Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FFE ❑ Other FEE <br /> INSPECTOR# S PERMIT VALID — to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# ' <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> Lill 0069 Pink Form Rcv.02/25/03 <br />