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ColorMake <br /> Natural Bathing Area Out of Service Pool/Spa Spa Rpol <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> Skilled Nursing Large Generator <br /> 11-60 <br />MASTERFILE RECORD INFORMATION PINK <br />48-02-034 <br />11/15/07 <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> Ice Plant <br />Produce Stand <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Capacity Vehicle # <br /> Chemical Toilets -—Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />PAYMENT <br /> RECEIVED <br />MAY 1 I 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Program Element <br />Inspector# <br /> Check# <br /> Cash <br /> License # <br /> Package Treatment Plant <br /> Other Fee <br />_____ Food Handler <br />_____ Invoice# <br />Date <br />iK No □ <br /> Day Ph,-X?? c? ^Night Ph <br /> Surcharge Fee <br />_ to- <br />Date <br />Accounting Office <br />t> /h I fQ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR iMENT <br />MASTERFILE RECORD INFORMATION FORM I <br /> .jXNew EH Program at Existing Facility DNew EH Program and New Facility <br />| Facility ID Program Record ID ' ______J <br /> <br />Facility Address /V <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 <br /> Commissary Dry storage only with Food Preparation DVending 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#----------------------------------. Sticker#-------- <br /> <br /> Mobile Food Prep Unit ________Make ---------------------------------------Vehicle Type _ <br /> Registration # License #-------------------------------- - Sticker #-------- <br /> <br /> <br />DAFRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit------- <br />PUPA 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 <br /> Silver Only (2222) <br /> Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <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) .. , r,, <br /> Hotel/Motel—Number of Units or ^mPt Institution -Number of Units---------------- <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTRgL <br /> Environmental Assessment UST-CAP Site □ Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediat.on Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <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) Pumper Vehicle Registration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill O Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of Units) <br />□ pXa^X7ePROnX(u4t5e°Care □ Skilled Nursing □ Large Generator □ Small Generator □ Lil™ted Hau'er <br />□ Transfer Station Veterinary Clinic Common Storage Facility □ 2-10 □11-60 □> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application_ Form <br />E GENCY Not|F|CATiON FORThis FACILITY and/or PROGRAM <br />CONTACT PERSON /j I (i,, I it ( <br />F^eW <br />$ Permit Valid___ <br />^-30^ Amount Paid ____ <br />Reviewed by Trt) cA H