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<br />Make Color <br />License # <br />to <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> Skilled Nursing Large Generator <br /> 11-60 <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />11/15/07 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility PNew EH Program and New Facility <br />Tons Generated Per Year <br /> Silver Only (2222) <br /> Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <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 /> Ice Plant <br /> Produce Stand <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation PVending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsD Prepackaged Goods Only <br /> Vehicle Type Color <br /> License # Sticker # <br />Vehicle Type <br /> Sticker # <br />harge Fee <br />^7/7 <br />CONTACT PERSON_______________________ <br />| Program Elementt Fee J: <br />Inspector# Permit Valid <br /> Check# Amount Paid’ <br /> Cash Reviewed by (^71 <br />__________ ________________ _______ _________ ___________________-j . J <br />|| Facility ID_____________________________________Program Record ID rteswas I <br />Facility Address i cJr <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 <br />Registration # <br /> Temporary Food Facility -Dates of operation from ___________ to __________ _______ <br />[iZSpecial Event Dates of operation from ( z7 / 7//^ , to (fl( <br />DAIRY PROGRAM (2000) ' ' ' I' ' f 7 <br /> Grade A Dairy Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <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 /> Other Fee <br /> Food Handler <br />INVOICE # , <br />Date <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <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) <br /> Hotel/Motel------Number of Units Jail or Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation 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) <br /> Pumper Vehicle Registration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <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 PWS EHD 46-02-003 Blue Application Form <br />\ Emergency Notification for this FACILITY and/or PROGRAM ,. . , <br />lliU/UA NightPh -4^31 <br />| Surcharge Fei <br />ID ,4/7/7 tO <br />Date <br />Accounting Office