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ENT <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> PBR (2231) PBR HHW (2236) <br /> Natural Bathing Area Pool Spa Out of Service Pool/Spa <br /> Kennel <br />CONTACT PERSON <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Surcharge Fi <br />I to <br />Date <br />Accounting Office <br />Number of chemicals: <br /> Program 2. Facility <br /> CE (2233, 2234, 2235, 2237) <br />Number of ASTs <br /> UIC Site <br /> Water Quality Remediation Site <br />Program Element Fee <br />Inspector # Permit Valid lc>l• <br />■0*Check # Amount Paid <br /> Cash Reviewed by <br />48-02-034 V <br />1/23/13 <br /> License # <br /> Package Treatment Plant <br />Square Footage <br /> with Food Preparation <br /> w/Meat Market only <br /> Vehicle Type <br />_________________ License # <br /> Vehicle Type <br /> License # <br />Food Handlers Course required: Yes No <br />□Vending Machines Number of Units <br /> Multiple Departments Prepackaged Goods Only <br />Color ___ <br />_ Sticker# <br />Color <br />_ Sticker# <br /> Ice Plant Produce Stand <br /> CFO A B <br />tECO^tD INFORMATION PINK <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <br />SAN JOAQUIN COUNTY F ' 'IRONMENTAL HEALTH DEPAR <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility_________________________DNew EH Program and Nev/ Facility <br />Facility ID ____Program Record ID I <br />Facility Address I6X& 3 tsu ipo<V ___________ <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 />I Registration # <br /> Temporary Food Facility -Dates of operation from <br /> Special Event—Dates of operation from <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) <br /> Aboveground Storage Tank Facility (AST) (2800) <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 <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup 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 Use (4120) <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp EvejiiMohiLaFatjlity (4131) <br />LIQUID WASTE PROGRAM (4200) rMT lylEN I <br />□ Pumper VehicleRegistration # License# Capacity RECEIVED <br /> Pumper Yard Package Treatment Plant Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) UL I U i ZUlO <br /> Landfill Transfer Station Ag/Cannery Waste Site <br /> Waste Tire Facility Compost Facility Process/Recycle Facility <br /> Refuse Vehicles (# of Units) Dumpsters > 20 cu yd (# of Units) lUfA^TILP^fl^TySWiTiup Site <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Transfer Station Veterinary Clinic Common Storage Facility 2-10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />r> Emergency Notification for this FACILITY and/or PROGRAM <br />UACMgCt. COaTO Day Ph S 2. ' fe^^ight Ph S 2 3 "3^2[ <br />IMS FEE J^ 2 p Surcharge F^e □ Other FEE <br /> Food Handler <br /> INVOICE# <br />Date / <br />MASTERFILE RECOI