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Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Out of Service Pool/Spa Natural Bathing Area Pool Spa <br /> Kennel <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 />3-0 <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 /> Color <br />Sticker # <br />_ Color <br />Sticker # <br /> Ice Plant Produce Stand <br /> CFO A B <br /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br /> CtaTfafRffilVyi/g, <br />--- W/f^y^lean <br />^r<^©Mif£/GAi7iited Hauler <br />□ ir^^r/Sfi^^^^feTiJfators <br />lupSite <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 Address <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 Vehicle Type <br />Registration # License # <br /> Mobile Food Prep Unit-- Make. Vehicle Type <br />Registration# License# <br />^Temporary Food Facility -Dates of operation from 3 • *2.0 to • 2-(£> • 2-0 <br /> Special Event-Dates of operation from 2) • > 2-Q to <br />Program Element <br />Inspector# <br /> Check # <br />P Cash <br />48-02-034 <br />1/23/13 <br />DAIRY PROGRAM (2000) <br />P Grade A Dairy <br />CUPA <br />P Hazardous Materials Business Plan (1900) <br />P CalARP Program P Program 1 Facility <br />P Hazardous Waste Generator (2200)------------>-Tons Generated Per Year <br />P Tiered Permitting Facility--------> P CA (2232) P CE (2233, 2234, 2235, 2237) P PBR (2231) P PBR HHW (2236) <br />P Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />P Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />P Other CUPA Program <br />HOUSING PROGRAM (2400) <br />P Hotel/Motel-----Number of Units P 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 />P Environmental Assessment P UST-CAP Site P Local HW Cleanup Site P NPL/SEP Cleanup Site P UIC Site <br />P Abandoned HW Site P non-NPL/SEP Cleanup Site P RWQCB Cleanup Site P Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br />P Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />P Body Art Practitioner Reg (4110) P Mechanical DSPS Notification (4115) P Body Art Facility-Single Use (4120) <br />P Body Art Facility-Sterilization (4121) P Body Art Temp Event Co-ord (4130) P Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />P Pumper VehicleRegistration # <br />P Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />P Landfill P Transfer Station <br />P Waste Tire Facility P Compost Facility <br />P Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care P Acute Care Skilled Nursing P Large Generator P Smal <br />P Transfer Station P Veterinary Clinic P Common Storage Facility P 2 -10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />■ ii Emergency Notification for this FACILITY and/or PROGRAM - <br />WilMg- DavPh glV-liu^-il^fZh 6)u■ Ulfg-qT-V <br />ms fee »l9Z-k) P Surcharge Fee <br />Permit Valid^p--2-| — to S - 3Z? ~ <br />Amount Paid Date <br />Reviewed by Accounting Office <br />P Other FEE <br />P Food Handler <br />Invoice # ___________________ <br />Date <br />masterfile record information pink