Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL;HEALTH DIVISION <br /> 'LVL-kSTERFILE RECORD Ii tFOIUNLAMON FORM(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH Program and New Facility <br /> Facility ID �_—A lVCt)-1 10 1 Program Record ID Plz� S S �-- <br /> FacilityAddress Wl r1 4L-D M G1�1 it- Ca. g15331c, <br /> (Please Check the appropriate description and specify sizg number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing 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 /> ❑ itilobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Regisrration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to Cl Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ iVlilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) hC ZZ 1-7 rApP I1 ckV,CP "C_ <br /> HAZARDOUS WASTE PROGRAM(2200) tt <br /> ❑ Hazardous Waste Generator--------------Tons Generated Per Year j <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pet-mit-By-Rule Household Hazardous Waste j <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) I <br /> ❑ Hotel/ivlotel-------Number of Units ❑ Jail or Exempt Institution Number of Units f <br /> Employee Housing(2700) Use Employee Hous nzlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ L IPL/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 PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) l <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) t <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) d <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units 1 <br /> d <br /> SOLID WASTE PROGRAM(4400) 1 <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 —E] 2- 10 ❑ 11 -60—❑>60 generators <br /> f <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAIM ELEMENT 22-1-7 FEE ❑Surcharge FEE ❑ Other FEE C <br /> INSPECTOR# WL[q, PERMIT VALID to ❑ Food Handler_ <br /> ❑ Check# AMOUNT PAID Date INVOICE# ' <br /> ❑ Cash REVMVED BY ACCOUNTING OFFICE Date )—P; 03 <br />