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to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Pool Natural Bathing Area Spa Out of Service Pool/Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <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 /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <br />PAYMENT <br />received <br />NOV 0 5 2015 <br />SAft JOAOUIN COUNTY <br />envihomental r <br />health department <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 /> to Ice Plant Produce Stand <br />Mo V (o 20/'S'" CFO A B <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 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-NPUSEP 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 Small Generator Limited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility 2 -10 Dll-60 □> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />l I /, /EMERGENey Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON 7dZ5 Uf l?l Ci J<if Day Ph^<( jT^y-^/^jNight PhG#>7J z 3 <br />Program Element I 5^ Fee / 0 □ Surcharge Fee □ other Fee <br /> <br />Inspector# PermitValiQ> /1IFood Hand,er <br /> Check# AmountPAipy Date '///5~//Invoice# _________ <br />□ Cash Reviewed by Accounting Office Date ///Gy^S <br />48-02-034 ' MASTERFILE RECbRtvfNFORMATION PINK <br />1/23/13 <br />SAN JOAQUIN COUNTY E ‘ 'IRONMENTAL HEALTH DEPARTF’“NT <br />, MASTERFILE KeCORD INFORMATION FORM <br />2)<iCtl.ew EH Program at Existing Facility z pw EH Program and New Facility <br />[ Facility ID Program Record ID <br />Facility Address id ) St l i <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 />c£21Special Event—Dates of operation from a|q\/ (q