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ENT <br />5^>pecial Event—Dates of operation from <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR (2231) PBR HHW (2236) <br /> Natural Bathing Area Pool Spa Out of Service Pool/Spa <br /> Kennel <br />CONTACT PERSON <br />lo^k Wlr <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 />Number of chemicals: <br /> Program 2 Facility <br /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <br />Program Element <br />Inspector# <br />Check # <br /> Cash <br />48-02-034 <br />1/23/13 <br />ew EH Program and New Facility <br />Program Record ID <br />•_____________ <br />harge Fee <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators' <br />____ _ .UILI I Y AND/OR EKUURAIVI . ■ s . ,Day Ph'^A"’ ^Sz-^n^ltgight Ph^^ <br /> Other Fee <br /> Food Handler <br />_ Invoice #_ _______ <br />Date <br />MASTERFILE RECORD INFORMATION PINk/ <br />Fee_ <br />____ Permit Valid <br />__ Amount Paid <br />Reviewed by <br />SAN JOAQUIN COUNTY F 'IRONMENTAL HEALTH DEPAR’ <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Faciiity <br />Facility ID <br />Facility Address <br />to . OaH <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) <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 <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup 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 ArtTemp 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 <br /> Transfer Station Veterinary Clinic Common Storage Facility 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Forni <br />Emergency Notification for this FACILITY and/or PROGRAM <br />tq$ c <br />^ 2- . Surcharge Fee <br />/(/z/Y to <br />/ isi. q-q Date <br />Accounting Office <br />'7 20,s <br />-----------------------■ -—*----------------------“------------------------ <br />(Please check the appropriate description and specify size, number of units and pertinent information.y^U'H <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes No <br /> Commissary Dry storage only with Food Preparation DVending Machines Number of Units <br /> Retail Market-—Square footage w/Meat Market only Multiple Departments Prepackaged Goods Only <br /> Mobile Food Vehicle—Make Vehicle Type Color <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 to W-HdZ-—( _______ Ice Plant Produce Stand <br />1 to IV-OZ-IK □ CFO □ A □ B