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<br />Sfzch^to <br />-Number of Units <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br />Q Permanent Cosmetics (4122) <br /> Skilled Nursing <br /> Surcharge Fee__ <br />_ t0. <br />AID / j b- O U Date <br />. rs Accoi iNTiNG Office <br /> Vehicle# <br /> -Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> Ice Plant <br />O Produce Stand <br /> Ag / Canneiy Waste Site <br /> Process/Recycle Facility <br />El Dumpsters > 20 cu yd —Number of Units <br /> UIC Site <br /> Water Quality Remediation Site <br />Square Footage Food Handlers Course required; Yes No <br />O with Food Preparation 0 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 /> License # <br /> Package Treatment Plant <br />Capacity _ <br />O Chemical Toilets <br />' to________________ <br /> Milk Dispenser—Number of Containers in Multi-Head Unit <br />Day Ph 2-4-~7- Night Ph <br /> Other FEE <br /> CpFood Handler <br />_____ Invoice#______ <br />7,^ Date <br />' 6 2010 <br />■ I , . ■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 Pennit-By-Rule Household Hazardous Waste <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------ <br />Employee Housing (2700) Use Employee Housin^/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Environmental Assessment UST-CAP Site Local IIW Cleanup Site NPL/SEP Cleanup Site <br /> Abandoned HW Site non-NPITSEP Qeanup Site RWQCB Cleanup Site <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. O Pool <br />VECTOR CONTROL PROGRAM (4000) <br /> O 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 O Transfer Station <br /> Waste Tire Facility O Compost Facility <br /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br /> Veterinary Clinic <br />Q Primary Care D Acute Care Q Skilled Nursing D Large Generator D Small Generator O 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 />CONTACT PERSON ~Tg< ~ <br />Program Element_ Fee___ / / Ctt <br />Inspector # Permit Valid . 2-0 ~ <br /> Check# AMOUNT £AII> / / $7 <0 D <br />n r’oeb R FVIFWFDiRY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />________ MASTERFILE RECORD INFORM ATION FORM <br /> New EH Program at Existing Facility PNew EH Program and New Facility <br />Facility ID _______Program Record ID S" <br />Facility Address j <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br />O Commissary D 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 />ElsSpecial Event —Dates of operation from <br />DAIRY PROGRAM (2000) < T> <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----