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<br />D Milk Dispenser—Number of Containers in Multi-Head Unit <br /> UST-CAP Site <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br />’it! .£LL2Z11 <br /> Capacity <br /> Chemical Toilets <br />_________ Vehicle# <br />-Number of Units <br /> Ice Plant <br /> Produce Stand <br />Program Element <br />Inspector# <br />(sh /■r.VV <br />V <br />4^.00 <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br />d Dumpsters > 20 cu yd —Number of Units <br /> Other FEE <br /> Food Handler <br />Invoice#______ <br />Date <br /> Landfill <br /> Waste Tire Facility <br />Q Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br />O Veterinary Clinic <br /> UIC Site <br />D Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br />O Farm/Ranch Cleanup Site <br /> Grade A Dairy Grade B Dairy <br />CUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator^--------- <br /> CRT Offsite Handlers (2218) <br />Tiered Permitting Facility----------------- <br />Day Ph 4/^ ! 1' Night Ph <br /> Surcharge Fee <br /> to <br />Date <br />Accounting Office <br />JNTBfPAID <br />4- <br /> License # <br /> Package Treatment Plant <br />^0% <br />4//V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM I <br /> New EH Program at Existing Facility PNew EH Program and New Facility <br />Facility ID , Program Record ID | <br />X-Facility Address SP'LJi <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 □Vending Machines -Number of Units----------------- <br /> Retail Market Square footage with Meat Market only Multiple Departments Prepackaged Goods Only <br />. Mobile Food Vehicle—-Make Vehicle Type-------------------------------------- Color---- <br /> <br /> <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 j \ to"7^4//.— <br /> Special Event —Dates of operation from 11 <br />DAIRY PROGRAM (2000) <br />_________ to _________ <br />to P l/i> ~ '2-60^' <br />h I I 0 <br />■ <br />-Tons Generated Per Year - 1 Recycle / Exempt System (2299) <br /> Silver Only (2222) i Appliance Recyclers (2217) <br /> Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Fixed Unit Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (USD PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br /> IIotcl/Motel------Number of Units Jail or Exempt Institution------Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3(X)0) <br /> Environmental Assessment DUST-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 Pool <br />VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> Tattooing (4121) Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper Vehicle—Registration# <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Transfer Station <br /> Compost Facility <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator D Limited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility---- 2-10------- 11-60------ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use EM'S EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON Li <br /> <br />: Permit Valid <br />amoun <br />Reviewed by