Laserfiche WebLink
SATIN JOAQUIN COUNTY ENVIRONNUNTAL HEALTH DI 'ION <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> ❑New EH Program at Existing Facility New EH Program and New Facili <br /> ty <br /> Facili ID /��8 Program Record ID /O6�)S/8-57-3 <br /> Facility Address luo <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C1 Restaurant: Searing Capacity Square Footage <br /> Food Handlers Course required: Yes❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units <br /> C1 Retail Market----Square footage 11 with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Color Type <br /> ❑ Mobile Food Vehicle---Make Vehicle Sticker# <br /> Registration# License# <br /> C3 Mobile Mobile Food Prep Unit--Make Type Color Sticker# <br /> Re;stration# License# <br /> ❑ <br /> to Ice Plant <br /> C3 Temporary Food Facility---Dates of operation from ❑ Produce Stand <br /> ❑ Special Event -Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> 13 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy ❑ Grade B Dairy <br /> CUP A ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) / �h ,S Mn <br /> °Hazardous Waste Generator---------------------Tons Generated Per Year 7 U'�+ <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(C ) <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 Bforms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> ❑ HoteUNlotel-------Number of Units <br /> mo Application Form <br /> Employee Housing(2700)Use Employee Nousin!/Lahor Ca <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment <br /> C1 UST-CAP Site C3 Local HW Cleanup Site ❑ NPL/SEP Cleanup Site [IUIC Site <br /> ❑ Abandoned HW Site C1 non-NPL/SEP Cleanup Site 11RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of pools/Spas at Facility C1 Pool ❑ Spa C1 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ 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) Vehicle# <br /> C1 Pumper Vehicle-Registration# <br /> License# Capacity <br /> C1 Pumper Yard g <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash e/Ash Site <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site g <br /> ❑ Process/Recycle cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator 11 Limited <br /> auler <br /> ❑ Primary Care 11 Acute Care generators <br /> 11 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11 -60—060 <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E90069 B1ue ALWIication Form <br /> ��^^ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMA <br /> CONTACT PERSON T�r"A /vim S Day Ph '93L- 35'06 Night Ph <br /> PROGRAlm ELEMENT Z 20 FEE Z 00.60 KSurcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID -7 /4/O a to /.71 13 O ❑Food Handler__- <br /> ❑ Check# AiIN1OiNf PAID Date INVOICE# y r�� <br /> ACCOUNTING OFFICE Date 7 -,Q D <br /> ❑ Cash REVIEWED BY Rev.07/07/99 <br /> Fu MAA PNK FORM.doc <br />