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IENT <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 />MAR 1 9 2019 <br /> 11-60 <br />CONTACT PERSON <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 /> 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 />CM" / to . □ Ice Plant Produce Stand <br /> to CFO A B <br />SAN JOAQUIN COUNTY VIRONMENTAL HEALTH DEPAI <br />MASTERFILE RECORD INFORMATION FpRM <br /> New EH Program at Existing Facility 0New EH Program and New Facility <br />Facility ID __Program Record ID ■2^'7 <br />Facility Address^j1’? <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 <br />____________ <br /> Sludge^^^couNTY <br /> CIA Landfg^jftRjNMENTAL <br />fbWSI___ <br />Permit Valid________________ <br />Amount Paid ' ^2^- — <br />Reviewed by <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-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 <br />LIQUID WASTE PROGRAM (4200) “AT IVIEIN I <br />□ Pumper VehicleRegistration # License# Capacity Vehicl^ECEIVED <br /> Pumper Yard Package Treatment Plant Chemical Toilets—Number of Units <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 />L-tfLxatu-Day Ph ^-Jo'^ght Ph I . <br />Program Element Fe Surcharge Fee Other FEE <br /> <br />Inspector# ________ ______ Permit Valid__ _________________ to ______________________ Food Handler_ <br />-E^check#______________ Amount Paid____________________ Date , ' / _____________ Invoice#_________ <br />□ Cash Reviewed by baurg £ • Accounting Office z^z^'Date <br />48-02-034 ’ 1 MASTERFILE R^CORfe INFORMATION PINK <br />1/23/13