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1ENT <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Muiti-Head Unit <br /> Program 3 Facility <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />Facility Address 1^0 1 <br /> Capacity Vehicle# <br /> Chemical Toilets -—Number of Units <br /> License # <br /> Package Treatment Plant <br /> Small Generator <br /> 11-60 <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation nVending 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 />irge Fbe1 <br />•CD <br />SAN JOAQUIN COUNTY ‘ 'VIRONMENTAL HEALTH DERAF <br />MASTERFILtc RECORD INFORMATION FORM <br />New EH Program at Existing Facility DNew EH Program and New Facility <br />Facility ID Program Record ID A Z-- <br />V'UA'jf j/i 1 cd | <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 |O □’S <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleauiip Site <br />'OSe^^rs <br />□ OtherF^”* <br />^Sj,Food Handler <br />Invoice #____________________ <br />Date (OI ii>!/S~ <br />MASTERFILE RECORD INFORMATION PINK <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />PUPA <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-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP 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 <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 />CONTACT PERSON Day Ph Night Ph <br />Program Element 1^95^ Fee j □ Surcharge Fi <br />Inspector# (C'-'! Permit Valid 'lO to <br />Check # 0^04 Amount Paid •CD Date <br />Cash Reviewed'By///;!V'= Accounting Office <br />48-02-034 <br />1/23/13