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to <br />D 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 Senice Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> Limited Hauler Skilled Nursing <br />CONTACT PERSON , ) <br />sSHZl 1 <br />Masterfile Record Pink <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd —Number of Units <br /> Ice Plant <br /> Produce Stand <br />Program Element <br />Inspector# <br /> Check #_ <br /> Cash <br />I 111 - _ I .............................- —--------------r ----- ----------- g <br />Program Record ID > Io ‘T* | <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> UIC Site <br />O 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 />PAYMENT <br />RECEIVED <br />AUG 1 7 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />___' to____ <br />L( <br /> License # <br /> Package Treatment Plant <br />Day Ph <br /> FEE H I Surcharge Fee <br />Permit Valid to <br />Amount Paid Date <br />Reviewed by (Sr? 0 Accounting Office <br />07^5*3 <br /> Restaurant: <br /> Commissary Dty storage only <br /> Retail Market —Square footage <br />LU 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 7/ f / <br />DAIRY PROGRAM (2000) <br /> Capacity Vehicle # <br />O Chemical Toilets------Number of Units <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility XNew EH Logram and New Facility <br />Facility ID 1 <br />Facility Address 7 <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) . <br />Seating Capacity Square Footage Food Handlers Course required: Yes No 0, <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 />■ f Z X <br />•Tons Generated Per Year ■ g Recycle f Exempt System (2299) <br /> Silver Only (2222) i Appliance Recyclers (2217) <br /> Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Fixed Unit I <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (US'!) 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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />I I Environmental Assessment D UST-CAP Site O Local HW Cleanup Site. D 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 O 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 /> Landfill <br /> Waste Tire Facility <br /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />O Primary Care D Acute Care Q Skilled Nursing D Large Generator D Small Generator <br />O Transfer Station O Veterinary Clinic d Common Storage Facility----Q 2-10-------O 11-60------O > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use FH'S EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />eV); £ DayPh NightPh <br />FEE ^7 □ Surcharge Fee □ Other FEE <br /> to< Food Handler <br />F { Q O Date I INVOICE# <br />Date <br />As-Ar