Laserfiche WebLink
` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD Pt 1FORNLkTION FORNI(EH 00 69) <br /> New EH Program at Existing Facility ew EH Program and New Facility <br /> Facili ID t ► DC LL'`L-(v Program Record ID S i Sb <br /> CGIay-4�✓ a� ��2a 1Q <br /> Facility Addressf VV �'� "� <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) 11 <br /> Square Footage Food Handlers Course required: Yes No <br /> 11 Restaurant: Searing Capacity Sq g ❑Vendin Machines—Number of Units <br /> ❑ Commissary El Dry storage only ❑ with Food Preparation g <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C1 Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to C1Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ElProduce Stand <br /> C1Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C3 Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) 221-"1 <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> C3Hazardous Waste Generator--------------------- <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 /> ❑ Jail or Exempt Institution Number of Units <br /> C3 IlotellMotel-------Number of Units <br /> vbor Camp Application Form <br /> Employee Housing(2 i00) Use EmplaVee Hnirsing/L <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment C1 UST-CAP Site ❑ Local HW Cleanup Site C3NPUSEP Cleanup Site ❑ UIC Site <br /> C1non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site C1 Water Quality Remediatiou Site <br /> C1 Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) E] Out of Service PooUSpa ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility Cl Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOOt BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) C] Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) ac <br /> Ca i Vehicle# <br /> C3 Pumper Vehicle—Registration# License# Capacity <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets—Numb.er of Units <br /> SOLID WASTE PROGRAM(4400) ElSludge/Ash Site <br /> C1 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility <br /> ❑ CIA Landfill Site <br /> El Waste Tire Facility C1 Compost Facility C3FarmfRanch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units C3 Dumpsters>20 cu yd—`lumber of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ <br /> ❑ Acute Care C1 Skilled Nursing <br /> C1 Common Storage Facility —Large Generator C1 Small Generator ❑ Limited Hau er <br /> 11 Primary Care [] 2_ Ip El 1 -60—❑>60 generators <br /> C1Transfer Station C1Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use <br /> PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> FEE 11 Surcharge FEE ❑ Other FEE <br /> PROGRAM ELEMENT� ❑ Food Handler`j PERMIT VALID to <br /> INseecroR# INVOICE# <br /> C1Check# AINIOL iT'PAID Date <br /> Date <br /> [I Cash REVIEWED 13YACCOUNTING OFFICE Rev.07/0799 <br />