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to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />INFORMATION PINK <br />Number of chemicals: <br /> Program 2 Facility <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br /> Commissary Dry storage only <br /> Retail Market—Square footage <br /> Mobile Food Vehicle -Make <br />Registration # <br /> Mobile Food Prep Unit-- Make <br />Registration # <br /> Temporary Food Facility -Dates of operation from <br />'^Special Event—Dates of operation from to <br />11 - ‘s? - IG? <br />change Fee <br />ll / IQ> <br />*12*)! I <br />L^>. <br />_______________ License # <br /> Package Treatment Plant <br />inis i t aNU/utx r zT'/Z" <br />Day Ph Ph <br />Fee \ Surcharge Fee_________ Other FEE <br />Permit Valid H /^/1 to 11 /S I I Q> □ Food Handler <br /> Amount Paid — Date 11 , Invoice# <br />Revievvet.by\j:.^--'''' Accounting Office . Date <br />C/OUltf MASTERFILE RECORI <br />SAN JOAQUIN COUNTY E' 'IRONMENTAL HEALTH DEPARTM ENT <br />MASTERFILE RECORD INFORMATION FORM <br />qp New EH Program at Existing Facility PNew EH Program and New Facility <br />|| Facility ID Program Record ID <br />Facility Address A/, <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) <br /> CalARP Program Program 1 Facility <br /> Hazardous Waste Generator (2200)------------> Tons Generated Per Year <br /> Tiered Permitting Facility--------> CA (2232) CE (2233, 2234, 2235, 2237) PBR (2231) 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 Jail or Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br />□ Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> Body Art Practitioner Reg (4110) Mechanical DSPS Notification (4115) Body Art Facility-Single . <br />□ Body Art Facility-Sterilization (4121) □ Body Art Temp Event Co-ord (4130) □ Body Art-Temp Event Mc^llp Fa^n^^41^31) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper VehicleRegistration # License# Capacity Vehrefeft^ £ QfUo <br /> Pumper Yard Package Treatment Plant Chemical Toilets -—Number of Brtite . ' <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station Ag/Cannery Waste Site SludgMitt^H.Sijit^ <br />□ Waste Tire Facility □ Compost Facility Process/Recycle Facility □ CIA Landfill Site /fi <br /> Refuse Vehicles (# of Units) Dumpsters > 20 cu yd (# of Units) Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing 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 EHD 46-02 003 Blue Application Form <br />■y _ Emergency Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />Program Element <br />Inspector #s&u <br /> Check # <br /> Cash <br />48-02-034 <br />1/23/13 <br />Square Footage Food Handlers Course required: Yes No^. <br /> with Food Preparation ^Vending Machines Number of Units <br /> w/Meat Market only Multiple Departments Prepackaged Goods Only <br /> Vehicle Type Color <br /> License # Sticker # <br /> Vehicle Type Color <br /> License # Sticker # <br /> Ice Plant Produce Stand <br /> CFO A B