Laserfiche WebLink
ESAIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERb'II.E RECORD PttFORIvIATIO`1 7ew <br /> I(EH 00 69) <br /> EH Pro:: <br /> ro and New Facility <br /> ❑ New EH Pro at Existing Facility � S7 S� <br /> Facili s <br /> ID G y Program Record ID <br /> Facility Address N'M5 �5 � <br /> E c�s�oc�- � �,c.� `�a� <br /> (please Check the appropriate description and specify siz <br /> FOODe•number of unit and pertinent tnformat�on.) <br /> PROGRAM(1600) <br /> S Footage Food Handlers Course regired: YFs❑ No ❑ <br /> C1 Restaurant:Restaurant: Searing Capacity q g ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments CCol1 prepackaged Goods Only <br /> C3 Mobile <br /> Type Sticker#Mobile Food Vehicle--Make License# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Produce Stand <br /> C1Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tots Generated Per Year <br /> C1 Hazardous Waste Generator --------------- ❑ Conditionall Exempt( <br /> CE) <br /> Tiered Permitting Facility ❑ Condiionally Authorized(CA) <br /> ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ Permit-By-Rule Fixed Umt <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)('_390)—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 /> ❑ HoteVMotel-------Number of Units licarion Form <br /> Employee Housing(2700) Use EmploYee Housing/Labor Camp.-I pp <br /> SITE MITIGATION(0) Use <br /> UNDERGROUND INJECTION CON7ROL(3000) <br /> Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> ❑ Environmental Assessment Cl UST-CA Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site <br /> UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup S <br /> RECREATIONAL HEALTH PROGRAM(3600) C] Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> Cl Pool C1 spa <br /> C] out of Service PooVSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM)(4100) ❑ Permanent Cosmetics(4122) <br /> C3 Tattooing(412 1) <br /> ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle#�— <br /> ❑ Pumper Vehicle—Registration# ❑ Chemical Toilets Number of Units <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) 1 [1Sludge/Ash Site <br /> ❑Transfer Station ❑ Ag/Cannery Waste Site [I CIA Landfill Site <br /> ❑ Landfill Process/Recycle Facility <br /> ❑ Compost Facility El Farm/Ranch Cleanup Site <br /> ❑ Waste Tire Facility P <br /> ❑ Refuse Vehicles—Number of Units� ❑ Dumpsters>20 cu yd—`lumber of Units <br /> MEDICAL WASTE PROGRAM(4500) (] Large Generator <br /> C3 Primary Care ❑ Small Generator ❑ Limited Hauler <br /> ❑ Acute Care C1 skilled Nursing❑ Common Storage Facility -- -- l0 C3I l -60—❑>60 generators <br /> C1Transfer Station ❑ Veterinary Clinic <br /> e PWS <br /> PUBLIC WATER SYSTEM PROGRAM(46COY NOTIFICATION <br /> STIF CA7 ONnFOR THIS FACILITY AND/OR PROGRAM <br /> EMERGEN Ph <br /> Day Ph right <br /> CONTACT PERSON ❑ Other FEE <br /> FEE ❑Surcbarge FEE <br /> FPROGRA,IAENIENT to ❑ Food Handler� � PERMIT VALID INVOICE# <br /> AMOUNT PAIDDate <br /> DateREVMVED BY <br /> ACCOuNMG OFFICE ,07107/99 <br />