Laserfiche WebLink
r SAN JOAQUIN COUNTY ENV1RONMENTAL HEALTH DIVISION <br /> NIASTERFILE R RD INFORMATION FORM(EH 00 69) <br /> ❑ Ncw til I Progran at Existing Facility ❑New Eli Pro ram and New Facility <br /> Facility IDProgram -- PAYMENT <br /> Record ID <br /> Facility Address qQ I , c,(\ 2 8 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) JUL <br /> FOOD PROGRAM(1600) SAN JOAQUIN ct;t; <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Cour4f, Ho ❑ <br /> Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> tr>: <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 Plaut <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 /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <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 11ST A and B forr►rs <br /> HOUSING PROGRAM(2400) <br /> ❑ 1-lotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee Ilousing(2700)Use Employee Housing/%abor Camp Application Form <br /> SIJE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ IIIC Site <br /> ❑ Abandoned IIW 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 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 ❑ Dumpstcrs>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 Ilauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----02- 10-------❑ I I -00------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON o Day Ph Night Ph <br /> PROGRAM ELEMENT a2 l 50FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# e,02-PERMIT VALID to ❑ Food Handler <br /> T <br /> heck# AMOUNTPAID �/o� 3�• Date INVOICE# <br /> ash REVIEWED BY ACCOUNTING OFFICE Date J <br /> EH 0069 PINK FORM.doc R v.07/07/99 <br />