Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Facility ID <br />Facility <br />❑New EH Proaram and New <br />Record ID <br />S CbU�ko'n ca, <br />(Please check the appropriate description <br />and specify size, number of units <br />and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ <br />Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ <br />Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ---Square footage <br />❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ <br />Mobile Food Vehicle—Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Mobile Food Prep Unit-- Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ <br />Special Event ---Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy <br />❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) --------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee HOusinalLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW 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 ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />�� Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Sing) 4 20 <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Cq-ord (4130) ❑ Body Art -Temp Eventtel�4131) <br />LIQUID WASTE PROGRAM (4200) ECEIVED <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant 11 Chemical Toilets ----Number of Umts <br />SOLID WASTE PROGRAM (4400) SAN JOA I <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site [Is[ .UNTY <br />❑ Waste Tire Facility 11 Compost Facility ❑ Process/Recycle Facility ❑ ORAS] <br />ENT <br />❑ Refuse Vehicles (#of Units) ❑ Dumpsters> 20 cu yd.(#ofunlls) ❑ 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 -10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />\\ YUK IKIO't'H1..IL11 IT ANUIUR�'RVVRHIVI <br />CONTACT PERSON\�At�55k (/� eF�\b'1 C''S Day PI{�1� L1�PI — G ow <br />Night Pte" <br />PROGRAM ELEMENTT NII O FEE LIS� ❑ Surchaf ge FEE 11 Other FEE <br />INSPECTOR# 9953 PERMIT VALID 8122 to 2f ❑Food Handler <br />C eck# AMOUNT PAID Date �L ZVOICE# <br />ash REVIEWED BY ACCOUNTING OFFICE Date 8 ,2.2. <br />G48-02-034 ` MAS I ERFILE RECORD INRORMATION PINK <br />1123113 <br />