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ColorMake <br />License # <br />to <br />B forms <br /> Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Permanent Cosmetics (4122) <br />Fee <br />dudj-t <br />MASTEHFILE RECOAD iWORMATiON PINK <br />KMfla <br />Hilj <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />1W®07 <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br />O Dumpsters > 20 cu yd (# a iMta) <br />Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br /> Recycle/Exempt System (2299) <br />O Appliance Recyclers (2217) <br />O Conditionally Exempt (CE) <br /> Permi!-By-Rule Household Hazardous Waste <br /> Ice Plant <br /> Produce Stand <br /> Milk Dispenser-Number of Containers in Multi-Head Unit _ <br /> License # <br /> Package Treatment Plant <br />Night Ph <br /> Other FEE ____ <br /> Food Handler <br />Invoice #..> . <br />Date 7///^/CZ3 <br />'S'Sg <br />JUL 07 ®!3 <br />Square Footage Food Handler* Course required; Yes No <br /> with Food Preparation O Vending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsO Prepackaged Goods Only <br />________ Vehicle Type Cotar <br /> License # Sticker # <br />Vehicle Type _ <br />Sticker # <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <br /> ■Tons Generated Per Year <br /> Silver Only (2222) ■□ Conditionally Authorized (CA) <br />O Permit-By-Rute Fixed Unit <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A <br />HOUSING PROGRAM (2400) <br />O HoM/Motel -—-Number of Units Jail or Exempt Institution —Number of Units <br />Employe* Housing (2700) Use Employee Houslno/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment O UST-CAP Site O Local HW Cleanup Site NPLISEP Cleanup Site O UIC Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup She Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Pool <br />VECTOR CONTROL PROGRAM (4000) <br />O Poultry Farm——Maximum number of birds <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />O Tattooing (4121) O Body Piercing (4120) <br />UQW WASTE PROGRAM (4200) <br />O Pumper Vehicle Registration H <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire FectUty O Compost Facility <br /> Refute Vehicles (» ot Units) __ <br />KEei^LSMIEP&CSBAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Transfer Station Veterinary Clinic Common Storage Facility O 2 -10 <br />PMS.UC WATER SYSTEM PROGRAM <46001 Use PWS EHD 46^02-003 Blue Application Form <br />Emergency NoTincAnos for this FACILITY and/or PROGRAM <br />CONTACT PERSON f\ PfftXC- Day PhZDV%t|-~277| <br />Program Element llo^S- Fee T 74^. <^O □ Surcharge Fee_____ <br />inspector#__________ Permit Valid yfa-Tz.?) to_7/z-3/^-3__ <br />13 Check# C/iLeJj't Amount Paid OC> Date In/iS <br /> Cash Reviewed by Accounting Office <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />__ _____________ MASTERFILE RECORD INFORMATION FORM <br />D New EH Program at Existing Facility PNew EH Program and New Facility <br />[TZcmty id 2.7 7 <57 Program Record ID <br />Facility Address13 £ Lz>dk,<'Ar-z4 S4. Lexl'f 754 ' <br />(Ptease check the appropriate description and specify size, number of units and pertinent Informatics ) <br />FOOD PROGRAM (16W) <br />O R»ete«rant pasting Capacity <br />O Commissary O Dry storoga only <br />O Retail Market—Square footage <br />O MolMte Food Vehicle -Make __ <br />Registration #_ <br /> Mobile Food Prep Unit <br />Registration # _ <br />O Temporary Food Facility -Dates of operation from <br />M Special Event Dales of operation from "J/ZZy/z ? <br />DAIRY PROGRAM (2S00) ’ ‘ <br /> Grade A Dairy Grade B Dairy <br />CUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />O Hazardous Waste Generator- <br />O CRT Offsite Handlers (2218) - <br />Tiered Permitting Facility--------