Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL IiEALTII DEPARTMENT <br />EH Program at Existing Facil <br />ID 001881 <br />Facility Address <br />SSo rU . 1" / s0/j <br />d ID <br />(Please Check the appropriate description and specify Ejjs number of units <br />FOOD PROGRAM (1600) _ <br />New <br />57Z) C-7-1 -J <br />pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Drystorage only ❑ with Food Preparation <br />❑ Retail Market —Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle—Make Vehicle Type _ <br />Registration# License# <br />❑ Mobile Food Prep Unit—Make Vehicle Type _ <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from - <br />❑ Special Event —Dates of operation from <br />DAIRY PROGRAM (2000) <br />to <br />R <br />EOENED <br />FEB 2 9 ZOO <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />FIEAUH DEPARTMENT <br />Geo Su <br />Food handlers Course required:. YES ❑ No <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />to ❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) . <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2216) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <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 />❑ Hotel/Motel —Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housiag (2700) Use Fmnforee7lousigK&bor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds _ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area - <br />❑ Kennel <br />TATTOO BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />UOUiD WASTE PROGRAM (4200) - <br />❑PumperVehicle—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 ❑ 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--❑ 2 - to — ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIPSEIID 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON �..EO •� U •ti 2�4 z—Day Ph `�l —2 �vjj'lo Night Ph <br />PROGRAM ELEMENT__L_J� <br />INSPECTOR# (oZt'a <br />Check # <br />FEE `s�r U ❑ s <br />'VALID eG to <br />AMOUNT PAID Qr &V Date <br />REVIEWED BY <br />ACCOUNTING OFFICE <br />❑ Other FEE _ <br />❑ Food Ilandier <br />Date <br />