Laserfiche WebLink
Oki °b <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HE l DEPARTMENT p/\) v� <br /> h1ASTERFTLE RECORD INF N FORM gEGE <br /> ❑New EH Program at Existing Facility ❑New Eli Program and New Facility N N U <br /> Q( 5 21 <br /> 17 <br /> Facility ID r2 ram Record ID ! SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Facility Address v (w� V01 HEALTH DEPARTMENT <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) 0 s 2-113? <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only 11with Food Preparation ❑Vending Machines-Number of Units <br /> 11Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> ❑ Special Event -Dates of operation from to ❑ 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 /> IIAZARDOUS WASTE PROGRAM(2200) a <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Reeyclers(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 housing(2700)Use Employee Ifousing-lLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL( 000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned I1W Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(36 09) <br /> Number of Pools/Spas at Facility_�� Pool 11 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 /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ElPumper 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—[] 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS F,IID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON r Day Ph��`7�— (o D 7( Night Ph aoQ-Q ba 3 q�S <br /> PROGRAM ELENI ( bkl- FEE 7- �'f 6• ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALID .14 ( a t0 �2 <br /> EN I 3 11 D s ❑ Food Handler I r <br /> 13 Check# b 6 AMO NT PAID p� s S Date y� l 81 0 g INVOICE# �n s l��jO 40 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE [! Date 4( 2- b fJ <br /> '" "' "'• a 1 U b 3 ��O 1 ( M�ctrrfilr RrrrrA VinL- <br />