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[c, h rd CMoi <br />ColorMake <br />License # <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Out of Service Pool/Spa Natural Bathing Area Pool Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> Skilled Nursing Large Generator <br /> 11-60 <br />CONTACT PERSON <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />11/15/07 <br />Program Element <br />Inspector# <br /> Check # <br /> Cash <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 /> 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 /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />' / / <br />rogram at Existing Facility <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 />7 - ? T -Y?------- <br />'S <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 />Facility ID Program Record 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 />emporary Food Facility -Dates of operation from <br />pecial 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 <br /> CRT Offsite Handlers (2218)--------------- Silver Only (2222) <br />Tiered Permitting Facility-------------------— 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 USTA 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 Emp/oyee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPUSEP 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 VehicleRegistration # <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 /> Day Ph Night Ph <br /> Fee j ' Surcharge Fee Other Fee <br />Permit Valid to Food Handler <br />Amount Paid $ qZ' Date / '' _ '________ Invoice # <br />Reviewed by-T^ Accounting Office ////A- Date