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<br />to <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility ir <br /> Pool Natural Bathing Area Out of Service Pool/Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />4 llto <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />_ Capacity_ <br /> Chemical Toilets <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />PAYMENT <br />RECEIVED <br />JAN’2 5 2016 <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> Spa <br />> Vehicle # <br />—Number of Units <br /> License # <br /> Package Treatment Plant <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FyORM <br /> New EH Program at Existing Facility BNew EH Program and New Facility <br />| Facility ID ’ Program Record ID 1 <br />Facility Address PavCOrY <br />(Please check the appropriate description and specify size, nun/ber 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 <br />Registration # <br /> Mobile Food Prep Unit- Make <br />Registration # <br /> Temporary Food Facility —Dates of operation from <br /> Special Event—Dates of operation from <br />CONTACT PERSON <br />Program Element <br />Inspector# <br /> Check #_ <br />•~lB~~Gash <br />48-02-034 <br />1/23/13 <br />Fee______________ <br />Permit Valid (///(- <br />_____ Amount Pai d <br />Reviewed byAW\ ) <br />Square Footage Food Handlers Course required: Yes KJ No <br /> with Food Preparation nVending Machines Number of Units <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 />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) Number of chemicals: <br /> CalARP Program Program-1 Facility Program 2 Facility <br /> Hazardous Waste Generator (2200)-----------> Tons Generated Per Year <br /> Tiered Permitting Facility--------> CA (2232) CE (2233, 2234, 2235, 2237) PER (2231) D^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 Housina/Labor Camo Application Form <br />SITE MITIGATION (2900) • UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation 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) [J Mechanical DSPS Notification (4115) Body Art Facility-Single Use (4120) <br /> Body Art Facility-Sterilization (4121) BodyArtTemp 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 02-10 011-60 O>60 generators <br />PUBLIC WATER SYSTEM program (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY’and/qr PROGRAM <br />Day Ph flight Ph <br /> Surcharge Fee Other Fee <br /> to / / a. o /i ~7 □ Food Handler <br />i / 6. Date / /9- S~" //r, Invoice# <br />Accounting Office Date <br />MASTERFILE record information pink