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T <br />; 0 1 2018 <br />to <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 /> Skilled Nursing Large Generator <br /> 11-60 <br />L <br />Z. <br /> Capacity Vehicle# <br /> Chemical Toilets -—Number of Units <br />PAYMENT <br />RECEIVED <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />Lodf 1. <br /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />a to _________ <br />-5 <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 /> 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 />4 j ^SAN JOAQUIN COUNTY <br />V O ENVIRONMENTAL <br />— HEALTH DEPARTMENT <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) <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-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 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 PROGRAMCONTACT PERSON . / .. yE z,, Day Ph Night <br />PROGRAM Element Fee ? Surcharge Fee Other FEE <br />Inspector# J Permit Valid to------------ ~~~—■ Food Handler <br /> check# Amount Paid Date / _________Invoice# z <br />□ Cash Reviewed by Accounting Office t ~ Date <br />48-02-034 ‘ ~’=== MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTIV <br />. _ MASTERFILE RECORD INFORMATION FORM <br />XJ New EH Program at Existing Facility DNew EH Program and New Facility <br />^Facility ID Program Record ID <br />Facility Address jl A M/cfca <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 Ay S 2e/A