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to D Milk Dispenser—Number of Containers in Multi-Head Unit Natural Bathing Area Out of Service Pool/Spa Spa Kennel Permanent Cosmetics (4122) uted Hauler Large Generator Skilled Nursing O Vehicle# -Number of Units Sludge/Ash Site CIA Landfill Site U Farm/Rauch Cleanup Site Ice Plant Produce Stand Ag / Cannery Waste Site Process/Recycle Facility Dumpsters > 20 cu yd —Number of Units UIC Site D Water Quality Remediation Site ho __________ ■' 2011) Capacity _ Chemical Toilets License # Package Treatment Plant froni ___ ■ i -Tons Generated Per Year - □ Recycle / Exempt System (2299) Silver Only (2222) i Appliance Recyclers (2217) □ Conditionally Authorized (CA) □ Conditionally Exempt (CE) Permit-By-Rule Fixed Unit Pennit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM (2400) □ Hotel/Motel-----Number of Units □ Jail or Exempt Institution-------Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CQNTROL(3000) Environmental Assessment UST-CAP Site Local HW Cleanup Site. NPIVSEP Cleanup Site Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site JUI~2S »A| ' Food Handler 11 O ^Invoice# US ( Date V X) P A 674 Day Ph Fee c O Surcharge Fee Permit Vaud . to. Amount Paid /1 5. —' Date Reviewed by Accounting Office SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT __________ MASTERFILE RECORD INFORMATION FORM piGlew EH Program at Existing Facility PNew EH Program and New Facility I Facility ID O Program Record ID Facility Address 2-^^ S /- S Tic,- (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) n Restaurant: Seating Capacity Square Footage Food Handlers Course required. Yes Cl No^I^ Commissary D Dry storage only D with Food Preparation Vending Machines —Number of Units Retail Market —Square footage_ with Meat Market only Multiple Departments O Prepackaged Goods Only . Mobile Food Vehicle—-Make Vehicle Type _ Color--------------------------- Registration #______License # Sticker #-------------------------------- Mobile Food Prep Unit-Make Vehicle Type Color--------------------------- Registration # License # Sticker #.----------- ^fremporary Food Facility-—-Dates of operation S^Special Event —Dates of operation from DAIRY PROGRAM (2000) □ Grade A Dairy □ Grade B Dairy CUPA State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) Hazardous Waste Generator---------- CRT Offsite Handlers (2218) Tiered Permitting Facility----------------- UST-CAP Site Local HW Cleanup Site. non-NPL/SEP Cleanup Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility D Pool VECTOR CONTROL PROGRAM (4000) Poultry Farm-------Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Tattooing (4121) Body Piercing (4120) LIQUID WASTE PROGRAM (4200) Pumper Vehicle—Registration # . Pumper Yard SOLID WASTE PROGRAM (4400) Landfill Transfer Station Waste Tire Facility Compost Facility Refuse Vehicles —Number of Units MEDICAL WASTE PROGRAM (4500) Primaty Care Acute Care Skilled Nursing Large Generator Small Generator 14 Transfer Station Veterinary Clinic Common Storage Facility----- 2-10------- 11-60------ PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S EHD 46-02-003 Blue Application Form Emergency Notification for this FACILITY and/or PROGRAM CONTACT PERSON MDay Ph 35/- ^47^ Night Ph Program Element I 0^ 2 Fee Surcharge Fee other Fee Inspector# 13 Check# (p Cash