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ENT <br />JuN <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 />lJ Skilled Nursing Lj Large Generator <br /> 11-60 <br />Number of chemicals: <br /> Program 2 Facility <br /> Capacity Vehicle# <br /> Chemical Toilets -—Number of Units <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />PAYMENT <br />RECEIVED <br />JUN 3 0 2016 <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <br />SAN JOAQUIN COUNTY . /IRONMENTAL HEALTH DEPAF <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility MNew EH Program and Nev/ Facility <br />Facility ID Program Record ID H11~] | <br />FacHity Address QI \M Rcl <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes No <br /> Commissary Dry storage only with Food Preparation nVending Machines Number of Units <br /> Retail Market-—Square footage w/Meat Market only Multiple Departments Prepackaged Goods Only <br /> Mobile Food Vehicle-Make Vehicle Type __________ Color <br />Registration# License# Sticker# ________ <br /> Mobile Food Prep Unit- Make Vehicle Type Color <br />I Registration#License# Sticker# <br />0 Temporary Food Facility -Dates of operation from JU|U U* to |(l/7-L)|V Ice Plant Produce Stand <br /> Special Event—Dates of operation from to CFO DaDB <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 Jaii 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 VehicleRegistration # <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 Smail 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 />o Emergency Notification for this FACIIJTY and/or PROGRAIVL <br />CONTACT PERSON Day Ph Ph <br />PROGRAM Element fee dfl VX)____________ □ Surcharge Fee □ Other Fee ________ <br />Inspector# | f)QH Permit Valid *1 (O to ~~ □ Food Handler____ <br />□ t? "7*7 ffi^AMOUNT Paid I O, Date, Invoice# <br />Cash Reviewed by Accounting Office Date <br />48-02-034 (J MASTERFILE RECORD INFORMATION PINK <br />1/23/13