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’NTSAN JOAQUIN COUNTY EN <br />to <br />O Milk Dispenser—Number of Containers in Multi-Head Unit <br />■Number of Units <br /> UST-CAP Site <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br />Q Permanent Cosmetics (4122) <br /> Skilled Nursing <br />CONTACT PERSON <br /> Landfill <br /> Waste Tire Facility <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd -—Number of Units <br /> Color <br />Sticker #_ <br /> Color <br />Sticker # <br /> Sludge/Ash Site <br /> CIA Landfill Site <br />O Farm/Ranch Cleanup Site <br />O Ice Plant <br /> Produce Stand <br />Program Element <br />Inspector # <br /> Check # _ <br /> Cash <br /> UIC Site <br /> Water Quality Remediation Site <br />48-02-034 <br />Program Record ID <br />Fee _ <br />Permit Valid <br />^144- Amount Paid <br />■ ' Reviewed by <br />4 (|Q(o t/ <br />3/^M <br />2904 <br />_________ Vehicle # <br />■Number of Units <br /> License # <br />O Package Treatment Plant <br /> Capacity_ <br />D Chemical Toilets <br />O Limited Hauler <br /> > 60 generators <br />d Grade A Dairy D 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 />■Tons Generated Per Year Recycle / Exempt System (2299) <br /> Silver Only (2222) 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 (UST) PROGRAM (2300) Use USTA 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(30Q0) <br />O Environmental Assessment d UST-CAP Site d Local HW Cleanup Site d NPL/SEP Cleanup Site <br />d Abandoned HW Site d non-NPL/SEP Cleanup Site d RWQCB Cleanup Site <br />MAR 2 9 <br />SAN JOAQUIN c(JUNTt <br />environmental <br />health department <br />Square Footage Food Handlers Course required: Yes d No d <br />d with Food Preparation dVending Machines -Number of Units <br /> d with Meat Market only d Multiple Departments d Prepackaged Goods Only <br /> Vehicle Type <br />_________________ License #_ <br /> Vehicle Type <br />License # <br /> <br />1— <br />payment <br />DECEIVED <br />ONMENTAL HEALTH DEPART <br />| MASTERFILE RECORD INFORMATION FORM __________ <br />d New EH Program at Existing Facility jZRJew EH Program and New Facility <br />| Facility ID Program Record ID P/USCTT-lJ’*? I <br />Facility Address t I "7 ^3 /T| 2cKe V c TH ~____________ <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />d Restaurant: Seating Capacity <br />d Commissary d Dry storage only <br />d Retail Market -—Square footage <br />d Mobile Food Vehicle---- Make <br />Registration # <br />d Mobile Food Prep Unit—Make <br />Registration # <br />Lj&femporary Food Facility----Dates of operation from <br />JSESpecial Event —Dates of operation from i <br />Z DAIRY PROGRAM (2000) <br />Y/rM*?------- <br />d Local HW Cleanup Site <br />d non-NPL/SEP Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility d Pool <br />VECTOR CONTROL PROGRAM (4000) <br />d Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />d Tattooing (4121) d Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />d Pumper Vehicle-Registration # <br /> d Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />d Transfer Station <br />d Compost Facility <br />d Refuse Vehicles—Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />d Primary Care d Acute Care d Skilled Nursing d Large Generator d Small Generator <br />d Transfer Station d Veterinary Clinic d Common Storage Facility-----d 2-10-------d 11-60------ <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />L-U c/C DayPh Sr'CFZ Night Ph <br />lu-qr Fee Surcharge Fee d Other Fee <br />Jgi2-7 Permit VALID to L/( 1 <=> (O d Food Handler <br />•S Date _______ Invoice# <br />Accounting Office Date ' /3 D /o Y <br />Masterfile Record Pink