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:NT <br />to <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR HHW (2236) <br /> Pool Spa Natural Bathing Area <br /> Kennel <br /> Skilled Nursing Large Generator <br />CONTACT PERSON <br />W7$7 <br />:CORD INFORM <br />Z3& <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Out of Service Pool/Spa <br /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending Machines Number of Units <br /> O 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 <br /> New EH Program at Existing Facility <br />| Facility ID <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br />O Commissary O 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 <br />Program Element pEE | OQ <br />Inspector# Permit Valid <br />□ Check # Amount Paid { <br />□ Cash Reviewed by Mi/hT _____ <br />ss34 ■■ <br />SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR’ <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program and New Facility <br />Program Record ID <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) Number of chemicals: <br /> CalARP Program Program 1 Facility Program 2 Facility <br /> Hazardous Waste Generator (2200)------------>-Tons Generated Per Year <br /> Tiered Permitting Facility--------> CA (2232) CE (2233, 2234, 2235, 2237) PBR (2231) <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-NPL/SEP 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 Use (4120) <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper Vehicle Registration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator Small General <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 />/ Emergency Notification for this FACILITY and/or PROGRAM <br />/ ■ I /; i ■ ■ . ■ ■ . V Day Ph ’ ~7 Night Ph <br />Fee t-'U □ Surcharge Fee " □ Other FEE <br />___________________ to Food Handler <br />' 9 Date • Invoice # <br />Accounting Office Date <br />MASTERFILE RECORD INFORMATION PINK <br /> CIA LamRl^^B. 7 <br /> Farnjl^pch Clea^jJJSite <br />...at^jEk^ymited^^er <br />□ 11 - ^^^e^ators