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to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR HHW (2236) <br /> Out of Service Pool/Spa Natural Bathing Area Pool O Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />S>SC! <br />Fee_ <br />Permit Valid <br />Amount Paid _ <br />Reviewed by <br /> Capacity Vehicle# <br /> Chemical Toilets —Number of Units <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 /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />M <br />payment <br />RECEIVED <br />SEP : ■>. <br />to <br />iu/r> //(? <br />, ■■ ■■ —-------- Z. <br /> License # <br /> Package Treatment Plant <br /> Surcharge Fee <br />t to — <br />\'3C^'' Date <br />Accounting Office <br />Square Footage Food Handlers Course required: Yes No <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 /> Ice Plant Produce Stand <br /> CFO A B <br />SAN JOAQUIN COUNTY <br />Day Ph I Night Ph <br /> Other Fee <br />- Food Handler <br />_ IN VO IC E # <br />Date <br />MASTERFILE RECORD INFORMATION PINK <br />SAN JOAQUIN COUNTY E 'IRONMENTAL HEALTH DEPART <br />MASTERFILE keCORD INFORMATION FORM <br /> New EH Program at Existing Facility mlew EHJ^rogram and Nev^ Facility <br />| Facility ID _______Program Recoi <br />Facility Address CCTlW T <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 />S Special Event—Dates of operation from I 0 9 /7 C? <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) <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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTP'OL (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 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 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 />Emergency Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON^ -S <br />Program Element | L? Fee <br />Inspector# Permit Valid <br /> Check# <br /> Cash <br />48-02-034 <br />1/23/13