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Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> Spa Out of Service Pool/Spa Pool <br />OEt^gnfiell 2018 <br />D <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 />Fee <br />Permit Valid / 2^, <br />Am ou <br />Reviewed bV <7' <br /> Capacity Vehicle # <br /> Chemical Toilets -—Number of Units <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes D 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 />[^T^^to Ice Plant Produce Stand <br />to CFO A B <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility_____ PNew EH Program and New Facility <br />Facility ID ____________ Program Record ID / <br />Facility Add re ss ___________________________ <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 />Ji Registration # <br />KKiemporary Food Facility -Dates of operation from <br /> Special Event-Dates of operation from <br />CONTACT PERSON <br />Program Element / k 7 S <br />Inspector # H <br />Check# 1 / y // <br />O Cash <br />48-02-034 <br />1/23/13 <br />i Night Ph <br />.-..arg'e Fee/ Other FEE <br />/ // yD Food Handler <br />7/7 7 TJv Invoice# z _ <br />7"/ Date ZW7 <br />MASTERFILE RECORD'INFORMATION PINK <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <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 Housing/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 Site <br />RECREATIONAL HEALTH PROGRAM (3600) rAY IV11N I <br />Number of Pools/Spas at Facility Pool Spa Out of Service Pool/Spa Area <br />VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) SAN jQAQUiN COUNTY <br />□ Body Art Practitioner Reg (4110) □ Mechanical DSPS Notification (4115) □ Body Art Facility-Sif^0lf?UNA1^‘Wj <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp ^^FWlSftfi^P5Mfil^'(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 />Day Ph <br /> Surchan <br />to <br />V ^2^ ~'~l Date / <br />Accounting Office z