Laserfiche WebLink
SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DIVISIOl`• <br /> MASTERFILE RECORD INFORMATION FORA EH 00 69 <br /> C1 New EH Program at Existing Facility New EH Pro ram and New Facility AUG 1 7 2000 <br /> Facility ID Pro ram Record ID ��� ?,® T � <br /> Facility Addresses <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square 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 ❑ 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 /> El Temporary Food Facility-----Dates of operation from <br /> to El Ice Plant <br /> [I Special Event - Dates of operation from <br /> to El Produce Stand <br /> DAIRY PROGRAM(2000) <br /> C1 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 /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <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 /> ❑ Jail or Exempt Institution------Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> EmployecfHo���1_ f7,-70 se Employee Housine/Labor Camp Application Form <br /> L <br /> TITIGATION(2900) ; UNDERGROUND INJECTION CONTROL(3000) <br /> vironmental Assessme t' ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> andoned HW Sit ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site El Water Quality Remediation Site <br /> EA.TF@Pt 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 /> 1:1 Kennel <br /> ❑ Poultry Farm--------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) <br /> License# Capacity Vehicle# <br /> ❑.Pumper Vehicle--Registration# <br /> ❑ Pumper Yard El Package Treatment Plant El Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ A /Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station g ry ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br /> P <br /> ❑ Refuse Vehicles--Number of Units <br /> ❑ Dum stern>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care 1:1 Acute Care ❑ Skilled Nursing ❑ Large Generator 11 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----02- 10----- -❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PFVS EH0069 Blue Application Form <br /> EMER <br /> GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM _O a v &3 5 cE 2— <br /> CONTACT PERSON ` 1. C'V L Z Day Ph ( 70°t) 3 j1'C'W$,1TIght Ph <br /> FINSPECTOR# <br /> M ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> PERMIT VALID t0 El Food Handler <br /> # AMOUNT PAID Date INVOICE# <br /> REVIEWED BY ACCOUNTING OFFICE Date <br /> Rev.07/07/99 <br /> EH 00,,9 PINK FORM.doc <br />