Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL:HEALTH DIVISION <br /> M STERFILE RECORD LYFOR�IATION FORbt(EH 00 69) <br /> New EH Pro at Existing Facility <br /> ❑New EH Pro and New Facility <br /> Facility ID OO�tb�6°6 Program Record ED <br /> Facility Address 1-30sN U~v <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: YES❑ No ❑ <br /> ❑ Restaurant: Seating Capacity - Square Footage <br /> ❑Vending Machines-Number of Units <br /> [I commissary ElDry storage only C3with Food Preparation <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C3 Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit—Make License# Sticker# <br /> Registraation# to _Cl Ice Plant <br /> 11 Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Daces of operation from <br /> to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade B Dairy C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> CUP A ❑ St Facility Surcharge(2399) <br /> HAZ�IFOUS WASTE PROGRAM(2200) Togs Generated Per Year <br /> �&jj Hazardous Waste Generator---------------- <br /> Tiered Permitting Facility ❑—Tt�onditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> L-fZnut-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)PROGRANI(2300)Use UST A and B(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> C1 HoteVNlotel-------Number of Units <br /> lica(iort Form <br /> Employee Housing(2100)Use E "ovee H us7r>>/LaAo Cama AnD <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/ <br /> SITE MITIGATION(2900) SEP Cleanup Site ❑ UIC Site <br /> leanup Site [3RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> C1 Abandoned HW Site ❑ non-NPUSEP C <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of pooWSpas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number ofbirds <br /> TATTOO BODY PIERCING PERMANENT C❑O BMEY IC PROGRAM <br /> O(q M(4100) E3 Permanent Cosmetics(4122) <br /> El Tattooing(4121) <br /> 120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity.acityVehicle# <br /> C1 Pumper Vehicle-Registration# �—. <br /> El Treatment Plant (3 Chemical Toilets—Number of Units <br /> C1 Pumper Yard - <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> El Landfill C3 Transfer Station ❑Ag/Cannery Waste Site❑ ProE3 CIA Landfill Site <br /> cess/Recyde Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Dumpsters Y>20 cu d—Number of Units ❑ FarmRtaach Cleanup Site <br /> C1Refuse Vehicles-Number of Units <br /> MEDICAL WASTE PROGRAM(4500) [3Small Generator ❑ Limited Hauler <br /> ❑ Primary Care LJ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ 11 -60 0>60 generators <br /> 13 Transfer Station ❑ Veterinary Clinic ❑ Common Stooge Facility —❑ '- l0-- <br /> -- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> Day Ph � Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> C1 Surcharge FEE <br /> YROGRA�1 ELEMENT FEE�� ❑ Food Handler� <br /> PERMIT VALID�� to <br /> INseeeroB# INVOICE# — <br /> AMOINT PAID Date <br /> IJ Check# , Date <br /> [IcashiE <br /> h REVVED BY <br /> ACCOUNTING OFFICE (tev.07107199 <br />