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V <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> Natural Bathing Area Out of Service Pool/Spa Spa Pool <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />Number of chemicals: <br /> Program 2 Facility <br />Day Ph-?z?7-'747- cf 3C> <br /> Surcharge Fee <br />__ to. <br />Date <br />Accounting Office <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 />Program Element <br />Inspector# <br /> Check # <br /> Cash <br />48-02-034 <br />1/23/13 <br />fa g, i e- <br /> License # <br /> Package Treatment Plant <br />i7/w‘-w <br />Night Ph <br /> Other FEE <br /> Food Handler <br />Invoice #__________________ <br />Date <br />MASTERFILE RECORD INFORMATION PINK <br />to <br /> <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 />I Facility ID Program Record ID | <br />Facility Address S . ' QVVP C/r <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity Square Footage Food Handlers Course requireBTSSyVkJD'S! <br /> Commissary Dry storage only with Food Preparation DVending Machines Number of Units <br /> Retail Market-—Square footage w/Meat Market only Multiple Departments PrepackageqP <br /> Mobile Food Vehicle--Make Vehicle Type C^M/7^q ; <br />Registration # License # Sticker # <br /> Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration# License# Sticker # <br />'□ Temporary Food Facility --Dates of operation from <7 ~to 202^0 □ |ce plant Produce Stand <br /> Special Event—Dates of operation from to CFO DaDB <br /> Capacity Vehicle # <br /> Chemical Toilets -—Number of Units <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) nPBR(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 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 />yy Emergency Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON CPk-At & i e HdrlniJ <br /> <br />Fee <br /> Permit Valid_ <br />Amount Paid___ <br />Reviewed by