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ColorMake <br />License # <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br />1=AYM£NT <br /> Skilled Nursing Large Generator <br />Fee <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />11/15/07 <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 /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> Ice Plant <br /> Produce Stand <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br />dl with Food Preparation ElVending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsD Prepackaged Goods Only <br /> Vehicle Type Color <br />License # Sticker # <br />Vehicle Type <br /> Sticker # <br />charge FgE „ <br />SAN JOAQUIN COUNTY i_..VIRONMENTAL HEALTH DEPART. .cNT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility PNew EH Program and New Facility <br />Facility ID 4 Program Record ID VY ?|| - <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 <br />Registration # <br /> Temporary Food Facility --Dates of operation from <br /> Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy <br />PUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator <br /> CRT Offsite Handlers (2218) - <br /> Tiered Permitting Facility-- <br />Night Ph___________ <br /> Other Fee <br /> Food Handler <br />ICE # . <br />--Tons Generated Per Year <br />-□ Silver Only (2222) <br />Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <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 D UST-CAP Site D Local HW Cleanup Site d NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation 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 /> Landfill Transfer Station Ag/Cannery Waste Site Sludge/Ash Site . „ ng/g <br /> Waste Tire Facility Compost Facility Process/Recycle Facility CIA Landfill ofte <br /> Refuse Vehicles (# of Units) Dumpsters > 20 cu yd (# of Units) Farm/Rag^ $^gy|^&jNTY <br />MEDICAL WASTE PROGRAM (4500) ENVlR0N^RTMENT <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator 1 <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 □11-60 Q > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Pl/lfS EHD 46-02-003 Blue Application Form <br />/T) Emergenc^Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON ------• Day Ph <br />Program Element Iv/i S Fee Surd <br />Inspector # Permit Valid I,/2^1 / to <br /> x€fcheck# ^0(2? Amount Paid Date_ <br /> Cash Reviewed by ryw Accounting Office