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INSPECTOR # <br />d Check # <br />El Cash <br />PROGRAM ELEMENT \ FEE 0 0 Surcharge FEE <br />to 1 3 <br />6 Date <br />ACCOUNTING OFFICE <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Tattooing (4121) 0 Body Piercing (4120) <br />pQuir) WASTE PROGRAM (4200) <br />Pumper VehIcleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />CI Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles If/ of Unite) <br />EIZQLcai9Laaa.211Clciflad ( 4500) <br />CI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2-10 0 11 -60 0 >80 generators • (4600) Use pws EHD 46-02-093 BILiv ADPIlmlon Form <br />EMLR ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM. <br />CONTACT PERSON \ 01A v Day Ph A V-1"--2 0 5— a 3c Night Ph <br />(Please check the appropriate description and spetIfy filze, j1101130r of unl and pertinent Information.) <br />EQQapii2gBAK (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required; Yes 0 No 0 0 Commissary 0 Dry storage only 0 with Food Preparation I:Vending Machines Number of Units 0 Retail Market—Square footage 0 with Meat Market only 0 Multiple Departments0 Prepackaged Goods Only Mobile Food Vehicle —Make 110\2 Vehicle Type Color <br />License # 7: 6 IT,(3 \.(,---(\ci\ Registration 1/ , Sticker # Mobile Food Prep Unit Make Vehicle Type Color Registration # <br />0 Temporary Food Facility —Dates of operation from to ID Ice Plant 0 Special Event Dates of operation from to 0 Produce Stand DAIRY PROGRAM (2000). <br />0 Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> <br />0 Hazardous Waste Generator —Tons Generated Per Year <br />0 CRT Offsite Handlers (2218) --------D Silver Only (2222) <br />Tiered Permitting Facility ---0 Conditionally Authorized (CA) <br />Permit-By-Rule Fixed Unit <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A arid B forms J-IOUSING PROGRAM (2400) <br />0 Hotel/Motel —Number of Units 0 Jall or Exempt Institution --Number of Units Employee Housing (2700) Use Employee HousinalLabor Camp Application Form <br />ITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site 0 Abandoned HW Site 0 non-NPL/SEP Cleanup Site 1:1 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) -1 <br />Number of Pools/Spas at Facility 0 Pool 0 Spa <br />VECTOR CONTROL. PROGRAM (4000) <br />CI Poultry Farm---Maximum number of birds <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AfAL, 0 <br />MASTERFILE RECORD INFORMATION FORM <br />8/4 208 New EH Program and New Facill <br />Pro ram Rtecord ID id. lir <br />Facility Address 3,-2ti0 '1447-4,4t <br />0 New EH Program at Existing Fac111.1 <br />Facilit ID <br />14L <br />REVIEWED BY <br />t, <br />PERMIT VALID <br />AMOUNT PAID <br />0 Package Treatment Plant <br />License # <br />Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Process/Recycle Facility 0 CIA Landfill Site <br />0 Dumpsters > 20 cu yd or units) 0 Farm/Ranch Cleanup Site <br />0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />License # <br /> Capacity Vehicle # <br />1:1 Chemical Toilets —Number of Units <br />0 Out of Service Pool/Spa <br />Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />CI Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />015-3 611 <br />0 Permanent Cosmetics (4122) <br />Sticker # <br />0 Natural Bathing Area <br />0 Kennel <br />7k 7 Jo5-35- <br />MA8TERFILE RECORD INFORMATION PINK <br />49-02-034 <br />11/15/07 <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date <br />0