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J <br /> 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 Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <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 /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation Vending Machines Number of Unrts <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 /> License # <br /> Package Treatment Plant <br />I <br />'i <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE-RECORD information form____ <br /> New EH Program a! Existing Facility ENew EH Program and New Facility <br />I Facility ID__________________________________Program Record ID <br />Facility Address ,S| ^£^1. <br />(Please check the appropriate description and specify size, number of units and pertinent information ) <br />AM (1600) <br /> Restaurant Seating Capacity <br /> Commissary Dry storage only <br />O 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__ to <br />EbSpecial Event—Dates of operation from (0[ ’ IC M^to 2-pPl <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 Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPUSEP 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 Pool <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 />□QUID WASTE PROGRAM (4200) <br /> Pumper Vehicle Registration # <br /> Pumper Yard <br />SOUP 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 Umited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility D2-10 nil-eo □>60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 4&-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM Ci<r'l <br />CONTACT PERSON 8 Day Ph 5^ 7S3 Night Ph 7 <br />Program Element 1695 Fee □ Surcharge Fee □ Other Fee----------------------- <br />Inspector# 4589 Permit Valid to □ Food Handler---------------- <br />□ check#____________ Amount Paid_________________ Date Invoice#^----------------------------- <br /> Cash Reviewed by Accounting Office Date <br />4802^34----------------------------------------------------------------------------------------------------- MASTERFILE RECORD INFORMATION PINK <br />1/23/13