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MAY <br />to from <br />to <br />O Milk Dispenser—Number of Containers in Multi-Head Unit <br /> Permit-By-Rule Household Hazardous Waste <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 />______Fee <br />Permit Valid <br />AmounttPaid _ <br />Reviewed by <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd —Number of Units <br /> Vehicle# <br />-Number of Units <br />D Sludge/Ash Site <br /> CIA Landfill Site <br />Q Farm/Ranch Cleanup Site <br /> Ice Plant <br /> Produce Stand <br /> UIC Site <br />Cl Water Quality Remediation Site <br />ox <br />PinV <br /> License # <br /> Package Treatment Plant <br /> Capacity _ <br /> Chemical Toilets <br /> Landfill <br /> Waste Tire Facility <br /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br /> Veterinary Clinic <br />11F <br />2 2008 <br />SAN JOAQUIN COUNTY <br />HEALTH DEPARTMENT <br /> payment <br />Received <br />Program Element \ \z>^ <br />Inspector# P------ <br /> Check # <br />O Cash <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 E <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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTRQL(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 D 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 <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator Limited Hauler <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 /> Day Ph - 5^2/ Night Ph ------------ <br />. D Surcharge Fee ___________ Other FEE <br /> to □ Food Handler <br />ITi Date ' Invoice# <br />Accounting Office Date <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility DNew EH Program and New Facility <br />| Facility ID FtA; C) D (ProgramRecord ID <br />Facility Address —CVAY—--------------— <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 U No U <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--------------------------- Registration # ___________ License if--------------------------— Sticker #----------------------------- <br /> Mobile Food Prep Unit-Make ________________ Vehicle Type-------------------------------------- Color--------------------------- Registration # License #--------------- - Sticker #-------------- <br />^Temporary Food Facility —-Dates of operation <br /> Special Event —Dates of operation from <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---------------- -