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<br />3.to <br />O Milk Dispenser—Number of Containers in Multi-Head Unit <br />-Number of Units <br /> UST-CAP Site <br /> Natural Bathing Area Out of Senice Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br />dR-m-nia <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br />El Dumpsters > 20 cu yd —Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br />EJ Farm/Ranch Cleanup Site <br />JOAQUIN COUNTY <br />ENVIRONMENTAL <br />’ '.TH DEPARTMENT <br /> Ice Plant <br /> Produce Stand <br /> Landfill <br /> Waste Tire Facility <br />PAYMENT <br />DECEIVED <br />JUL -1 2011 <br /> UIC Site <br /> Water Quality Remediation Site <br /> to <br /> License # <br /> Package Treatment Plant <br /> Capacity Vehicle # <br />O Chemical Toilets------Number of Units <br />Square Footage Food Handlers Course required: Yes No <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 /> Primary' Care O Acute Care Skilled Nursing Large Generator Small Generator Limited Hauler <br /> Transfer Station O Veterinary Clinic Common Storage Facility O 2 - 10------- 11-60 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S EIID 46-02-003 Ulue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM F' <br />CONTACT' PERSON < '■ ■- Day Ph Night Ph 1 - ’ * <br />Program Element^ FEE D Surcharge Fee D Other FEE <br />Inspector# Permit Valid . to __________ □ Food Handler <br /> □ Check# VlS Ar AMOUNT Paid I • O D Date Invoice#. <br /> Cash Reviewed by Accounting Office . / Date ( <br />CC = —Masterfile Record Pink <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />□ New EH Program at Existing Facility /E^ew Eft Program and New Facility <br />Facility ID 1Program Record ID — | <br />Facility Address 1 ;----------------— <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—Make <br />Registration # <br /> 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-------------Tons Generated Per Year Recycle / Exempt System (2299) <br /> CRT Offsite Handlers (2218) Silver Only (2222) i Appliance Recyclers (2217) <br />Tiered Permitting Facility—--------------- Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Fixed Unit Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (USD 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 ffoiisinp/I^bor 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 <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 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 /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br /> Veterinary Clinic