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ColorMake <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br />CONTACT PERSON <br />74 <br />MASTERFILE RECORD INFORMATION PINK <br /> Other Fee <br /> Food Handler <br />Invoice# <br />Date <br />Program Element <br />Inspector# <br /> Check # . <br />O Cash <br />48-02-034 <br />11/15/07 <br />Tons Generated Per Year <br /> Silver Only (2222) <br /> Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <br /> Ice Plant <br /> Produce Stand <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of units) <br /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />• <br /> License # <br /> Package Treatment Plant <br /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 <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 />/■N'iCvWt PxS DayPh Night Ph <br />_ fFee <br />Vk-X'-A Permit Valid <br /> Amount PAiDy <br />Reviewed by <br /> Surcharge Fee <br />to <br />DatPAYMENT— <br />Accounting 0FFid§EOjE}\/ED <br />JUL 2 5 2012 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation OVending 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 />License # Sticker # <br />ation from to__________________ <br />Maa24;/710 A1/V9H5e 4-3//2- <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM | <br /> New EH Program at Existing Facility DNew EH Program and New Facility <br />| Facility ID Program Record ID , | <br />FaciIity 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 /> Temporary Food Facility -Dates of operaj^on from <br />-^Special Event Dates of operation from_t <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-------- <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <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 <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 /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care