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ENT <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR HHW (2236) <br /> Natural Bathing Area Pool Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br />□11-60 <br />S* <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 />5/(7//^ <br /> CFO A B <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />ge Fee <br />____ License # <br /> Package Treatment Plant <br />CONTACT PERSON <br />Program Element { (Fee -^-i , . <br />Inspector # Permit Valid 5 <br /> check# Amount Paid <br /> Cash Reviewed by <br />48-02-034 <br />1/23/13 <br /> Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> non-NPL/SEP Cleanup Site RWQCB Cleanpy^|y|5J^fater Quality Remediation Site <br />□ ou,»fSECflVfD <br />APR 1 2 2019 <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) <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 <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) <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 />Tgency Notification for this FAQ1LITY and/i <br />K f6( A c? Day Pl{^ <br />p Surcharge Fr <br />____ to <br />T^Date <br />..- Accounting Office <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br /> Mechanical DSPS Notification (4115JHEAUrB@SfWr^§&*iTity-Single Use (4120) <br />SAN JOAQUIN COUNTY /IRONMENTAL HEALTH DEPAR <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility_________________________DNew EH Program and New Facility <br />Facility ID 9?T Program Record ID || <br />Facility Address j| I S- Si- <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 required: Yes No <br /> Commissary Dry storage only with Food Preparation QVending 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 />IjzFemporary Food Facility -Dates of operation from 5 / I 7 / I to 5 / (7 / Ice Plant Produce Stand <br /> Special Event—Dates of operation from to <br />LIT,Y and/or PROGRAM <br />Night Ph <br /> Other Fee <br />_ Food Handler <br />_ Invoice# <br />Date W/f <br />masterfile reCord-information pink