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Surch4rge Ff E <br />to 12AI <br />Date <br />El Cash REVIEWED BY ACCOUNTING OFFICE <br />1/23/13 <br />48-02-034 <br />(Gsre, <br />PROGRAM ELEMENT I 1.0 . FEE <br />INSPECTOR # 10 PERMIT VALID <br />0 Check # b -AMO NT PAID <br />0 Other FEE <br />El Food Handler <br /> INvoicE# 3/ 1) <br />Date <br />MASTERFILE RECOR INFORMATION PINK <br />Food Handlers Course required: YES CI No El <br />OVending Machines Number of Units <br />0 Multiple Departments El Prepackaged Goods Only <br />Color <br />Registration # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant El Produce Stand <br />CI Special Event---Dates of operation from to 0 CFO CI A CI B <br />Sticker # <br />Color <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # <br />Chenabilktajeumber <br />of Un Vehicle aV ay # <br />El Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />El Large Generator El Small Generator El Limited Hauler <br />CI Common Storage Facility CI 2 - 10 <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 TO /1 Day Phil 3 75 -Y611-'7 Night Ph <br />0 1 1 - 60 El >60 generators <br />SAN JOAQUIN COUNTY E .RONMENTAL HEALTH DEPART :NT <br />MASTERFILE RECORD INFORMATION FORM <br />*ew EH Program at Existing Facility EINew EH Program and New Facility <br />Facility ID Program Record ID Re05 -473&? <br />Facility Address .2_67On rc-f f 201 1AV2k_-5baleY ) <br />(Please check check the appropriate description and specify size, nurrAer of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage <br />CI Commissary CI Dry storage only El with Food Preparation <br />CI Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />License # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program Cl Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />El Tiered Permitting Facility > El CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) El 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 />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment 0 UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site El UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site El RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />El Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (413 <br />E <br />LI <br />gicEr,i i .vE,%Facility-Single Use (4120) % <br />PUTemp Event Mobile Facility (4131) <br />SOLID WASTE PROGRAM (4400) <br />CI Pumper Yard El Package Treatment Plant El <br />SAN JOAQUIN COUNTY <br />El Landfill CI Transfer Station El Ag/Cannery WaAtigNINIONMENTAL <br />El Waste Tire Facility 0 Compost Facility El Process/RecycleM1t9EPARTIVENT <br />El Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care El Acute Care ID Skilled Nursing <br />El Transfer Station CI Veterinary Clinic