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ENT <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> Natural Bathing Area Out of Service Pool/Spa Spa Pool <br /> Kennel <br />CONTACT PERSON <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Capacity <br /> Chemical Toilets — <br /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />SyAT/f! <br />__________ Vehicle # <br />-Number of Units <br /> License # <br /> Package Treatment Plant <br />( <br />Night Ph <br /> Other Fee <br /> Food Handler <br />_____ Invoice# __________ <br /> Date ________ <br />MASTERFILE RECORD INFORMATION PINK <br />Program Element <br />Inspector# <br /> Check # <br /> Cash <br />48-02-034 <br />1/23/13 <br />PAYMENT <br />RECEIVED <br />MAY 2 7 2015 <br />health DEPARTMENT <br />Fee i-2} 0h Fee_ <br />Permit Valid <br />______ Amoullp-Paid _ <br />Reviewed byz <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <br />SAN JOAQUiN COUNTY 1 fIRONMENTAL HEALTH DEPAR <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility PNew EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address r 14t ___________ <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 <br />Square Footage Food Handlers Course required: Yes Mo <br /> with Food Preparation DVending 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 />~7— to — ~7 —( Ice Plant Produce Stand <br /> to ~~ CFO A B <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) 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)□ 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-CAPSite 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 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 <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 />~Day Ph □ST0 <br /> Surcharge Fee <br />to <br />_ Date <br />Accounting Office