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1 PROGRAM ELEMENT 2.2.2.4 FEE <br />r- <br />INSPECTOR # Ob2-kp PERMIT VALID to <br />' 0 Check, # AMOUNT PAID Date <br />0 Cash REVIEVIED 13`Zpifrit ACCOUNTING OFFICE <br />48 C2-C:'.4 <br />0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />0 Refuse Vehicles (#0, Units) 0 Dumpsters > 20 cu yd <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br /> 121rcharge FEE 419 0 Other FEE <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />Food Handler <br />VOICE # <br />Date 2, <br />1.1.ASTERFILE RECC:P.1, II4F0F1.1:-TION Pini <br />' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> <br /> MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility EH Program and New Facility <br />It. Facility ID 04-10)2 5 1 C Program Record ID I q6,10 <br />Facility Address Camp 1U, Maii4e_t_ct DISPO <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation EVending Machines Number of Units <br />0 Retail Market----Square footage 0 vdMeat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />0 Special Event---Dates of operation from to 0 CFO DAUB <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy El Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number of chemicals. <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />"573r-klazardous Waste Generator (2200) > Tons Generated Per Year,?..,„: t) <br />0 Tiered Permitting Facility > 0 CA (2232) U CE 12233. 2234 2235. 2237) U PBR 2231 U PBR HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2300) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 Hotel/Motel Number of Units 0 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 />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />0 Abandoned HW Site U non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />0 Pumper VehicleRegistration # License # Capacity Vehicle # <br />!