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<br />Make Color <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Natural Bathing Area Pool Spa Out of Service Pool/Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />CONTACT PERSON <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />8/02/12 <br /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <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 /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />__ License # <br />/ / 3 <br /> to <br />piplew EH Program and New Facility <br />Program Record ID P <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending 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 />6 / (/ 3 <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) <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-NPL/SEP 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 /> Body Art Practitioner Reg (4110) Mechanical DSPS Notification (4115) Body Art Facility-Single Use (4120) <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp Event Mobile Facility (4131) <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 □ LbrnfteoWfiJMiT <br /> Transfer Station Veterinary Clinic Common Storage Facility 2 -10 11-60 > <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form JUN 1 8 2011 <br />Emergency Notification for this FACILITY and/or PROGRAM <br />GLwJl Day Ph Night Ph SAN JOAQUIN COUNTY <br />/ ' =—— ----------' ------=——------------ ENviHOMEHTALProgram Element Fee n Surcharge Fee □ Other Fe^ealth DEPARTMENT <br />Inspector# Permit Valid to Food Handler <br />□ check#_______________ Amount Paid Date 0/f? /13_________Invoice# <br />j^Cash Reviewed by TVq Accounting Office Date <br />SAN JOAQUIN COUNT 4VIRONMENTAL HEALTH DEPA . MENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility <br />|| Facility ID <br />Facility Address <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 />0 Temporary Food Facility -Dates of operation from <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-------------