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<br />NOV <br />to <br />D Milk Dispenser—Number of Containers in Multi-Head Unit <br /> Permit-By-Rule Household Hazardous Waste <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kenuel <br /> Permanent Cosmetics (4122) <br />60 generators <br />CONTACTPERSON <br />DO <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd —Number of Units <br /> Vehicle# <br /> •Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br />D Farm/Ranch Cleanup Site <br /> Ice Plant <br /> Produce Stand <br /> UlCSite <br /> Water Quality Remediation Site <br />s <br />Facility IP <br />Facility Address <br />\ I I—7 /Q / <br />11 /°l ;7 <br /> Capacity _ <br /> Chemical Toilets <br /> License # <br /> Package Treatment Plant <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 />2 2007 <br />SZtN JDaquin COUNTY <br />Mfa^t2jRONMENTAL <br />healtu DEPARTMENT <br />payment <br />ReceivedSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />□ New EH Program at Existing Facility ~^New EH Program and New Facility <br />0 I KUc? Program Record ID <br />“V f <9 io t> o <0 iC X- d £- <br />jwT <br />E-r <br />J.... <br /> Skilled Nursing Large Generator Small Generator Limited Hauler <br /> Common Storage Facility----- 2-10------- 11-60------ <br /> Landfill <br /> Waste Tire Facility <br /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care <br /> Transfer Station Veterinary Clinic <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 />Day Ph f.XV- <br />Program Element Fee 9 T- oo O Surcharge Fee <br /> <br />Inspector # / Permit Valid . } U C? V to. <br />jyi Check# Amount Paid Date <br /> Cash ______Reviewed by S’ >7 Accounting Office <br />Night Ph _____________ <br /> Other FEE <br /> Food Handler <br />Invoice#___________ <br />Date G/^lOy <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 /( / H [ O'! <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- <br /> CRT Offsite Handlers (2218) <br />Tiered Permitting Facility-------- <br />-Tons Generated Per Year ______ 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 'P------ -- a <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 /> Hotcl/Motel------Number of Units Jail or Exempt Institution------Number of Units <br />Employee Housing (2700) Use Employee Ifousin^/Labor Camp Application Farm <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(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 />u I °~l <br />______________ <br /> UST-CAP Site Local HW Cleanup Site. <br /> non-NPL/SEP 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