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OCT 9 2007 <br />to <br />D 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 />O Permanent Cosmetics (4122) <br /> Limited Hauler Skilled Nursing <br />CONTACT PERSON <br />Program Element <br />Inspector# <br />S^Check#_ <br /> Cash <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PAYMENT <br />RECEIVED <br /> Ice Plant <br /> Produce StandET Si>eciaI Event —Dates of operation from <br />DAIRY PROGRAM (2000) <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd —Number of Units <br /> UIC Site <br /> Water Quality Remediation 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 /> License # <br /> Package Treatment Plant <br /> Capacity Vehicle # <br /> Chemical Toilets------Number of Units <br /> to <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ’'T^Ljcw EH Program and New Facility <br />| Facility ID ‘VCD / * Program Record ID 0 / | <br />Facility Address -S 7~r; aJ 57s'o <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 D Nod <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 />Registration #_License # Sticker # ----------------------------- <br /> Mobile Food Prep Unit-Make _____ Vehicle Type------------------------------------- Color--------------------------- <br />Registration # License # Sticker # ---------.----- <br /> Temporary Food Facility—-Dates of operation from <br />0. Special Event —Dates of operation from / ° /1 7 / OV <br />• i' <br />-Tons Generated Per Year _____ Recycle ! Exempt System (2299) <br /> Silver Only (2222) 1 Appliance Recyclers (2217) <br /> Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Fixed Unit Pennit-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 /> HoteVMotd------Number of Units Jail or Exempt Institution------ <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Farm <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CQNTROL(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 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 Y ard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill O Transfer Station <br /> Waste Tire Facility Compost Facility <br />D Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing O Large Generator O Small Generator <br /> Transfer Station Veterinary Clinic Common Storage Facility----- 2-10------- 11-60------ > 60 generators <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 />DayPh NightPh <br />I FEE t/O Surcharge Fee ___________ O Other FEE <br />____ Permit Valid to; □ Food Handler----------------- <br />__Amount Paid ' 9 Y ■ ctj Date Invoice # <br />Reviewed by D 3 2 / Accounting Office Date