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>00 I> <br />Q Milk Dispenser—Number of Containers in Multi-Head Unit <br />-Number of Units <br /> UST-CAP Site <br /> Natural Bathing Area <br /> Kennel <br />O Permanent Cosmetics (4122) <br /> 11-60 —B& <br />CONTACT PERSON <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd -—Number of Units <br /> Vehicle # <br />■Number of Units <br />O Ice Plant <br />O Produce Stand <br /> License # <br /> Package Treatment Plant <br /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfdl Site <br />O Farm/Ranch Cleanup Site <br />Q Out of Service Pool/SpaO Spa <br />iler <br />'generators <br />OCT - 4 2000 <br />P ™IMENHtO I CrJTClOU <br /> Capacity __ <br /> Chemical Toilets <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation □Vending Machines --Number of Units <br /> with Meat Market only Multiple Departments Prepackaged Goods Only <br /> Vehicle Type Color <br /> License # Sticker # <br /> Vehicle Type Color <br /> License # Sticker # <br />5??^- <br />_________ to____ <br />to 2C? - /5"-00 . <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator <br />□ Transfer Station □ Veterinary Clinic □ Common Storage Facility -—□ 2-10-------□ 11-60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EH0069 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />Day Ph............ Night Ph sTjWS <br /> □ Surcharge Fee □ Othei^W^0NML" <br /> to Food Handler <br />Date INVOICE# ! <br />Accounting Office ' Date <br />Rev. 07/07/99 <br />Program Element Fee <br />Inspector # Permit Valid <br />□'Check # tP-t \Amount Paid <br />Fl Cash Reviewed by <br />EH 0069 PINK FORM.doc <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—-Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br /> Hotel/Motel------Number of Units Jail or Exempt Institution------- <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30QO) <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 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 <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br /> Veterinary Clinic <br />SAN JOAQUIN COUNTY E1N 7IRONMENTAL HEALTH DIVISION <br />MASTERFILE RECORD INFORMATION FORM (EH 00 69) <br /> New EH Program at Existing Facility PNew EH Program and New Facility <br />Facility ID u Program Record ID <br />Facility Address x&Di Cu<-tu.*ih. <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 /> Temporary Food Facility----Dates of operation from <br />^Special Event - Dates of operation "from /O ~ lS~ <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy <br />CUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator-------------------------Tons Generated Per Year <br />Tiered Permitting Facility Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit