Laserfiche WebLink
RF YMFNT <br /> C�c�VED <br /> sANo� R 202023 <br /> p. ENV AQUIN <br /> SAN JOAQUINnCO NT LE RECORD ENTA T EAORMDEPARTMENT H�A�T DE q�T �T)' <br /> T <br /> ❑New EH PMUram at Existing Facility ❑New EH Pr ram and New Faclli <br /> Facili ID Q Program Record ID rRO549 <br /> Facility Address.Laby Cl2}PE F�3Tfi/b(_- ljj1 Lccxgr—o29 5T, ��� gQ-YD <br /> (Please check the appropriate description and specify size,number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES❑ No❑ <br /> ❑Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑w/Meat Market only ❑Multiple Departments❑Prepackaged Goods Only <br /> ❑Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# Slicker# <br /> ❑Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility-Dates of operation from to ❑Ice Plant❑ Produce Stand <br /> 2!rSpeclal Event—Dates of operation from o to []CFO ❑A❑B <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dalry ❑Grade B Dairy ❑Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑CalARP Program ❑Program 1 Facility ❑Program 2 Facility ❑Program 3 Facility <br /> ❑ Hazardous Waste Generator(2201)—>-Tons Generated Per Year <br /> ❑Tiered Permitting Facillty—> OCA(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 UST A and B forms <br /> i ❑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 Houslna/Labor Camp Appllcatlon 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 ❑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—Ma>amum number of birds ❑ Kennel <br /> TATTOO.BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Body Art Practitioner Reg(4110) ❑Mechanical DSPS Notification(4115) ❑ Body Art FacllitySingle Use(4120) <br /> ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle 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 V of Unns) ❑Dumpsters>20 cu yd(k ofurrts) ❑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 112-10 ❑ 11-60 ❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON NISK>€ M,;GLl.i;2�C/t` Day Ph Nlght Ph 2-0'1—y 7/ -5y?6 <br /> PROGRAM ELEMENT FEE J!o ❑ Surcha s EE ❑Other FEE <br /> INSPECTOR# PERMIT VALID ) to `� 7 11 Food Handler <br /> ❑Check# 1, I V— AMOUNT PAID �/, Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02"034 MASTERFILE RECORD INFORMATION PINK <br /> 123113 <br />