Laserfiche WebLink
SAN JOAQUIN COUNTY <br />AL HEALTH DEP <br />Facility Address —245 v y lt6 s-&vA (1t "_v&__, <br />(Pieese Check the appropriate description and specify E!Z number of units and pert, <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating CapacitySquare Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market —Square footage ❑ with Meat Market only <br />and New Facility N <br />1 FP RM 14161 620,98 <br />yLcq <br />nformation.) �FRI/i� q(Ty <br />_k J <br />Food Handlers Course required: - Yrs ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ 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 ❑ 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 />HAZAWUS WASTE PROGRAM (2200) <br />azardous Waste Generator Tons Generated Per Year {73 N ❑ Recycle I Exempt System (2299) <br />❑ CRT Offsite Handlers (221 g) ❑ Silver Only (2222) _ 13 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 farms <br />HOUSING PROGRAM (2400) <br />❑ note/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Fmnfovee HonsinyEabor 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site 1 ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ P901 <br />VECTOR.CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds _ <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ pumper Whicle—Registration# License# Capacity vehicle #_ <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />❑ Spa [3 Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag l Cannery Waste Site ❑ Sludge/Ask Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,I.andfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Duirpsters > 20 cu yd —Number of Units ❑ Farm/Raach Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care . ❑ Acute Care ❑ SkilledNursing❑ 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 EIID 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THis FACILITY AHD/OR PROGRAM <br />CONTACT PERSON p Day Ph Night Ph <br />PROGRAM ELEMENT -2 _L_2-� FEE (5 \ •� 5 ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# O PERMIT VALID L to \2I 3 � ❑ Food Handler <br />Elec <br />Chk# Jate INVOICE# Ing ' y� 196 <br />❑ Cash REVIEWED BY M r _ AccoutFrING L (A Date 3 1 % 9,11 C) p <br />_ sir �� 1k�! • C�!tia>•' • - <br />