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0 Surcharge FEE <br />to /5‹ • <br />El Other FEE <br />CI Food Handler <br />INVOICE # 30 3 7 6)C---> <br />Date /( <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 /--1/) h Ajr.1 ttAij-Q/') Day Ph(Z:407.3)Z 5 ,?b(c. Night Ph <br />/7 ACCOUNTING OFFICE <br />6;00:U3 - 5;L'; <br />PROGRAM ELEMENT I Ito FEE 0 <br />INSPECTOR # 59q9 PERMIT VALID <br />CI Check # AMOUNT PAID Date <br />pCash REVIEWED BY <br />Food Handlers Course required: YES CI No CI <br />:Wending Machines Number of Units <br />1:1 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # 7A1 2.. (fi tiE Sticker # <br />Vehicle Type Color <br />License # Sticker # . <br />PA Ytit, Capacity Vehiclen <br />0 Chemical Toilets ----Number of Units <br />SAN JOAQUIN COUR E IRONMENTAL HEALTH DE ZT ENT <br />MASTERFILE RECORD INFORMATION FORM <br />.14,New EH Program at Existing Facility <br />ONew EH Program and New Facility <br />Facility ID rk-Z)D 2.2M 440 Program Record ID , <br /> <br />Facility Address 1, ()rt., <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Fo otage <br />Commissary 0 Dry storage only 0 with Foo d Preparation <br /> <br />4141, Mobile Food Vehicle --Make <br />Retail Market----Square footage <br /> <br />Registration # <br />0 w/Meat Market only <br />CI Mobile Food Prep Unit-- Make <br /> <br />Registration # <br />CI Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />CI Special Event—Dates of operation from to CI CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CU PA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 PBR HHW (2236) <br />1:1 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />CI 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 CI UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site 0 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 CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard CI Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />MEDICAL WASTE PROGRAM (4500) <br />Landfill CI Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler <br />ii?CI Ag/Cannery Waste Site 0 Sludge/As bite i 20p <br />CI Process/Recycle Facility 0 CIA La flripill <br />CI Dumpsters > 20 cu yd (# of Units) 0 Fa rrtifik piiittOiSktp <br />uEPAR riva.LN 7, <br />0 Common Storage Facility 0 2-10 0 11 -60 0 >60 generators CI Transfer Station 0 Veterinary Clinic <br />48-b2-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13