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to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> Spa Out of Service Pool/Spa Pool <br /> Skilled Nursing Large Generator <br /> 11-60 <br />CONTACT PERSON <br />7^ <br /> Capacity Vehicle# <br /> Chemical Toilets —Number of Units <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 /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />to <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending 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 />Day Ph Night Ph Tt/l- <br /> Surcharge Fee <br /> to <br />— Date <br />/X'^/accounting Office <br /> Other FEE <br />_ Food Handler <br />_ Invoice#_ <br />Date <br />MASTERFILE RECORD II..ORD INFORMATION PINK <br />SAN JOAQUIN COUNTY E' 'RONMENTAL HEALTH DEPART 'NT <br />MASTERFILE RECORD INFORMATION FORM <br />ffiNew EH Program at Existing Facility DNew EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address ' <br />(Please check the appropriate description and specify size, number 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 />'Vnfemporary Food Facility -Dates of operation from <br />Jap Special Event—Dates of operation from <br />Program Element <br />Inspector# <br /> Check #_ j <br /> Cash <br />48-02-034 <br />1/23/13 <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 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) <br /> Body Art Facility-Sterilization (4121) I <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 />n Emergency Notification for this FACILITY and/or PROGRAM <br />Fee — <br />Permit Valid <br />Amount Paid <br />Reviewed by <br /> UIC Site <br /> Water Quality Remediation Site <br />PAYMENT <br />rea <br />□ ^r)i^el2 8 2018 <br />iviecnamcai uoro Notincation i io; □ Body Art Facility-Si^g^QseCMW?®V3^^ <br /> Body Art Temp Event Co-ord (4130) □ Body Art-Temp EveirtJAb'Bl'lP^&ftity (4131)