Laserfiche WebLink
+SAN JOAQUIN COUNTY EY RONNIENTAL HEALTH DEPART" TENT <br />NIASTERFILE I` ORD INFORNIATION FORM <br />New EH Pro am at Existing Facili ❑New EH Pro ramandNew Facility <br />Facility ID Program Record ID CL 052, l,, 0(0(1 <br />Facility Address e�-�{ 1+0 0L� <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ 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 />❑ Nlobile Food Vehicle -----Make Vehicle Type <br />Registration # License # <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-Flead Unit <br />CUPA ❑ 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 ---------- ❑ 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 fonn.c <br />HOUSING PROGRAM (2400) <br />❑ IioteUMotel-------Number of Units ❑ Jail or Exempt Institution ---Number of Units <br />Employee (lousing (2700) Use Employee Housing/Labor Camp Applications 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 ❑ 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4 12 1 ) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />ElChemical Toilets ------Number of Units <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 ❑ Dumpslers > 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 ----- 112-10 ------ ❑ 11 - 60 ------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT L f—] (� 0 FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERMIT VALID to ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date •=�j j �.�j <br />Masterfile Record Pink <br />Il l`iV3 <br />