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^PR / 7 20/7 <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-I id Unit <br /> Program acility <br />R (2231) PBR HHW (2236) <br /> Pool Out of Service Pool/Spa Natural Bathing Areapa <br /> Kennel <br /> Chemical <br /> 11-61 <br />a <br />ipacity Vehicle# <br />ITsulets —Number of Units <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 />.4400) <br /> Transfer Station <br /> Compost Facility <br /> <br /> □ CE (2233, 2234, 2235, 2237) □ <br />Number of ASTs <br />k Program (UST) (2300) Use UST A and B forms / <br /> Small Geneh^tor Limited Hauler <br /> > 60 generators <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation CVending 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 />echanical DSPS Notificatibn (4115) Body Art Facility-Single Use (4120) <br />Body Art Temp Event Co-orcb(4130) Body Art-Temp Event Mobile Facility (4131) <br /> License # <br /> Package Treatment Plant <br />Program Element, <br />Inspector# <br /> Check #. <br /> Cash <br />48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY Eb’ RONMENTAL HEALTH DEPARTS NT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility PNew EH Program and New Facility <br /> <br />| Facility ID Program Record ID / MOsY//./r-. <br />^.Facility Address <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 J J *7 <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardobs Materials Business Plan (1900) Number of chemicals: <br /> CalARP Prdgram Program 1 Facility Program 2 Facility <br /> Hazardous WEiste Generator (2200)------------> Tons Generated Per Year <br /> Tiered Permittingyacility--------> CA (2232) <br /> Aboveground Storage.Tank Facility (AST) (2800) <br /> Underground Storage 1 <br /> Other CUPA Program <br />HOUSING PROGRAM (2400) <br /> Hotel/Motel------Number of Units Jail o/Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Hpusinq/Labor Camp Application ^orm <br />SITE MITIGATION (2900) <br /> Environmental Assessment UST-CAP Site <br /> Abandoned HW Site non-NPL/SEP <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm-------Maximum number of birds /X <br />TATTOO, BODY PIERCING, PERMANENT COSMETICJ^ROGRAM (4100) <br /> Body Art Practitioner Reg (4110) <br /> Body Art Facility-Sterilization (412 <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper VehicleRegistratioj <br /> Pumper Yard <br />SOLID WASTE PROGRAI <br /> Landfill / <br /> Waste Tire RKmity <br /> Refuse Vehicles (# of units) <br />MEDICAL W^STE 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 />\ , I i. Emergency JMotification for this FACILITY and/or PROGRAM _ <br />Contact person /WZfrVA Ph y^c-xight Ph <br />.__________ FEE -< J Surcharge Fee Other FEE <br /> Permit Valid 'M'S//? to Food Handler <br />___ Amount Paid 0_ Date Invoice# __________ <br />Reviewed bxt; / ■ Accounting Office ^777 7/n//~7 <br />MASTERFILE RfeCORfalNFORMATION PINK <br />UNDERGROUND INJECTION CONTROL (3000) <br /> Local HW/fleanup Site CrNPL/SEP Cleanup Site UIC Site <br />teanup Site /□ RWQCB Cleanup Site Water Quality Remediation Site