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RONMENTAL HEALTH DEPART NT <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR HHW (2236) <br /> Spa Natural Bathing Area Pool >a <br /> Kennel <br /> 11-60 <br />CONTACT PERSON <br />nt Pai s. <br />Number of chemicals: <br /> Program 2 Facility <br /> Capacity Vehicle# <br /> Chemical Toilets —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 />to <br />' .— Surch; <br /> to <br />1^2-^ Date <br />Accounting Office <br /> License # <br /> Package Treatment Plant <br /> Mechanical DSPS Notification (4115) <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending Machines Number of Units J <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 Pla,nt Produce Stand <br /> CFO A B <br />SAN JOAQUIN COUNTY E <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility <br />| Facility ID <br />Facility Address '2X0 <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 />j£^Special Event—Dates of operation from | <br />Program Element I <br />Inspector# <br /> Check# VIS.#— <br /> Cash <br />48-02-034 <br />1/23/13 <br />UNDERGROUND INJECTION CONTROL (3000) <br /> Local HW Cleanup Site NPL^ifP Cleanup Site UIC Site <br />isaiWtf%jU£>»*L3_Water Quality Remediation Site <br />n nfipeN®’ <br /> Out ol^ftvice Pow <br />Facil <br />) Body Art-Tern I <br />__________^Pfoew EH Program and New Facility <br />______ Program Record ID ( | <br />b.____$■€ (n\ U <br />.11 Y ANDjOR MKOUKAIVI r/.2/2^- IM <br />je Fee Other Fee <br />__________________ Food Handler <br />_ Invoice#______ <br />Date <br />MASTERFILE record information pink <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) <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) <br /> Environmental Assessment UST-CAP Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cl <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) <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130)’ <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 />/ A Emergency Notification for this FACILITY and/or PROGRAM <br />l\A(l AllZ/ Day~Ph <br />, J Fee_ <br />_ Permit Valid <br />Amount Paid _ <br />Reviewed by WU /\ <br />)T^*tvice Po^U <br />,rt Facility-Single Use (4120) <br />Body Art-Temp Event Mobile Facility (4131) <br />larg