Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />IvLASTERFILE RECORD LNFORttiL4TION FORN1(EH 00 <br />New EH Pro am at Existing Facility ❑New EH Program and New Facility <br />Facility LD b0 _ Program Record ED �' `� �C 7 <br />Facility Address Gq 2 CAP ADIl A -w <br />(Please Check the appropriate description and specify size• number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Searing CapacitySquare Footage Food Handlers Course required: Yes 11 No C1 <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Nlarket ---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle ---Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />W <br />_ Color <br />Sticker # _ <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <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 />XHazardous Waste Generator ------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (Ct) <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 />❑ HotellMotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee NourinelLahor 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 HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site '4"- ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # _ <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />11C1 Landfill C1 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 />C3 Primary Care C1 Acute Care ❑ Skilled Nursing ❑Large Generator ❑Small Generator 11 Limited Hauler <br />0 —❑ > 60 generators <br />El Transfer Station ❑ Veterinary Clinic C1 Common Storage Facility —❑ 2 - 10 ❑ it - 6 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />D L <br />(XP) C, Day Ph— �Night Ph <br />PROGRAMELEENIENT_%2`ZO_ FEE I <br />1,NSPECTOR # D PERMIT VALID <br />❑ Check # <br />AMOUNT PAID <br />RFVTEWED BY <br />❑ Surche F E ❑ Other FEE <br />to V-1I <br />y ❑ Food Handler�— <br />Date <br />ACCOUNTING OFFICE <br />INVOICE # ' <br />Date <br />Rev. 07/07"99 <br />