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NT <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> Out of Service Pool/Spa Natural Bathing Area 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 Sludge/Ash Site <br /> Process/Recycle Facility CIA Landfill Site <br /> Dumpsters > 20 cu yd (# of Units) Farm/Ranch Cleanup Site <br /> UIC Site <br /> Water Quality Remediation Site <br /> License # <br /> Package Treatment Plant <br />CONTACT PERSON <br />Program Element / r| <br />Inspector# 3, ^ I <br /> Check # <br /> Cash <br />48-02-034 <br />1/23/13 <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 /> Ice Plant Produce Stand <br /> CFO A B <br />SAN JOAQUIN COUNTY Ef RONMENTAL HEALTH DEPART <br />_____ MASTERFILE RECORD INFORMATION FORM __ <br /> New EH Program at Existing Facility ______ DNew EH Program and New Facility <br />Facility ID 3 Program Record ID I '15' <br />FacilityAddress <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 />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 <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 (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 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 />______________________ Day Ph Night Ph <br />FEE [ , O Surcharge Fee,/ □ Other FEE <br /> <br />I Permit Valid / to , Food Handler <br /> V^cS^- Amount Paid ~Date *^7 Invoice # / <br />Reviewed by Accounting Office Date <br />’=== /3 ( masterfile record information PINK