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-NT <br />irom / <br />^1(^1 /o to <br /> Milk Dispenser —Number of Containers in Multi-Head Unit <br /> UST-CAP Site <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br />CONTACT PERSON <br />[N< <br />Square Footage <br /> with Food Preparation <br /> Limited Hauler <br /> 11 60----- > 60 generators <br />D Sludge/Ash Site <br /> CIA Landfill Site <br />Ci Farm/Ranch Cleanup Site <br /> Ice Plant <br /> Produce Stand <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd —Number of Units <br /> UlCSite <br /> Water Quality Remediation Site <br /> New EH Program at Existing Facility <br />I Facility ID <br />Facility Address <br />-31^ ■— <br /> Record Pink <br /> License # <br /> Package Treatment Plant <br /> Capacity Vehicle # <br /> Chemical Toilets------Number of Units <br />IUIN COUNTYI -^^WfiONMENTAL <br />I HEALTH department <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity Square Footage______________ Food Handlers Course required Yes U No^ <br /> Commissary Dry storage only with Food Preparation Vending Machines -Number of Units----------------- <br /> Retail Market —Square footage with Meat Market only Multiple Departments Prepackaged Goods Only <br /> Mobile Food Vehicle —Make _ Vehicle Type-------------------------------------; Color--------------------------- <br /> Registration #__ ________ License #---------------- Sticker # -------------- <br /> Mobile Food Prep Unit-Make ________________ Vehicle Type------------------------------------.. Color--------------------------- <br /> Registration # License #-------------------------------- Sticker #-------------- -------------- <br /> Temporary Food Facility —-Dates of operation from <br /> Special Event —Dates of operation from <br />DAIRY PROGRAM (2000) <br /> Landfill <br /> Waste Tire Facility <br /> Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br /> Veterinary Clinic <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----------------- <br /> - <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT £ EP / J <br />MASTERFILE RECORD INFORMATION FORM I Mqu/m ’ <br />J^lew EH Program and New Fa< <br />pt'Q) S I L? Program Record ID o <br />' r x—Tons Generated Per Year ■■ Recycle / Exempt System (2299) <br /> Silver Only (2222) i Appliance Recyclers (2217) <br />— Conditionally Authorized (CA) El Conditionally Exempt;(^p):'\JT' <br /> Permit-By-Rule Fixed Unit Permit-By-Rule ttcrasefrold Ha^rdous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (USD PROGRAM (2300) Use UYT/l unrf B forms <br />HOUSING PROGRAM (2400) SA£^BQli!ME^AL1TY <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 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 /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator <br /> Transfer Station Veterinary Clinic Common Storage Facility----- 2-10 <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 />A Day ph ( -J' Night ph <br />Program Element Fee □ Surcharge Fee Pother Fee <br /> <br />Inspector# C PermitValid ■ to________;______________ □ Food Handler <br /> V^€heck # Amount Paid / /6 ~ ^^"--^Date 7 / _jCA Invoke # — <br />□ cash 2- Reviewed by AccorTNTiNbOmcE '^2-2-■ Q O ; , Date