Laserfiche WebLink
% I). <br />ColorMake <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Natural Bathing Area Out of Service Pool/Spa Spa Pool <br /> Kennel <br /> Permanent Cosmetics (4122) <br />CONTACT PERSON <br />MASTERFILE RECORD INFORMATION PINK <br />■—Tons Generated Per Year <br />— Silver Only (2222) <br />■— Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Ice Plant <br /> Produce Stand <br />48-02-034 <br />11/15/07 <br /> UIC Site <br /> Water Quality Remediation Site <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />License # <br />ltd <br /> License # <br /> Package Treatment Plant <br />Night Ph <br /> Other FEE <br /> Food Handler <br />Invoice# <br />Date <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 />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 ip P^D5y/77/4J I <br />Facility Address IJ . lAAftA^T) t <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 />/0''Temporary Food Facility —Dates of operation from <br /> Special 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 Generator1 <br /> CRT Offsite Handlers (2218) - <br />Tiered Permitting Facility-------- <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <br /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br />Program Element <br />Inspector#_______ <br />D Check # <br />O Cash <br />ee <br />Permit Valid ■l)-y22- <br />AmountPaid <br />Reviewed by-’^P — <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 />O Environmental Assessment UST-CAP Site D Local HW Cleanup Site NPUSEP Cleanup Site <br /> Abandoned HW Site D non-NPUSEP Cleanup Site D RWQCB Cleanup 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 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 /> Primary Care Acute Care Skilled Nursing O 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 />< {I Emergency Notification for this FACILITY and/or PROGRAM <br /> Surcharge fEE <br />. to <br />Date~ S'! — <br />Accounting Office