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<br />to <br /> Pennit-By-Rulc Household Hazardous Waste <br /> Natural Bathing Area Out of Sendee Pool/Spa Spa <br /> Kennel <br />O Permanent Cosmetics (4122) <br /> Skilled Nursing <br />Masterfile Record Fink <br />r Zt? I 1 <br /> Milk Dispenser—Number of Containers in Multi-Head Unit <br /> Ag / Cannery Waste Site <br /> Process/Recycle Facility <br />O Dumpsters > 20 cu yd —Number of Units <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />O Ice Plant <br /> Produce Stand <br /> UIC Site <br /> Water Quality Remediation Site <br />___ to ___________ <br />z/ 2b ZJ <br />/Z7._ <br /><TO Date <br />Accounting Office <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation Vending Machines -Number of Units <br /> with Meat Market only Multiple Departments Prepackaged Goods Only <br /> Vehicle Type Color <br /> _________________ License# Sticker# <br /> Vehicle Type Color <br />License# Sticker# ■----------- <br />MAR 2 » <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator D Limited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility---- 2-10------- 11-60------ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PH'S EIID 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />'nnAg'7-^Ann^^/f^payPh—^G'3-~? / Nishtr>h------- — <br />FEE j ' L 1 _________ O Surcharge Fee __________ Q Other FEE <br />Permit Valid . to 111___________ □ Food Handler------------------ <br />Amount Paid oO Date S [ Invoice # <br />Reviewed by Accounting Office Date <br /> Capacity Vehicle # <br /> Chemical Toilets------Number of Units <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility J3Ncw EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address j( 0 Q 0~7 Th J - <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-Make <br />Registration # <br /> Temporary Food Facility----Dates of operation from <br />Q 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) i <br /> Hazardous Waste Generator------------Tons Generated Per Year - _ Recycle I Exempt System (2299) <br /> CRT Offsite Handlers (2218) Silver Only (2222) i Appliance Recyclers (2217) <br />Tiered Permitting Facility— --------------- Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Fixed Unit L <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA 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 Housin^/lMbor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPI7SEP Cleanup Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site <br />CONTACT PERSON f\)d7yW\ <br />Program Element I G. 7 <br />Inspector# Vl 7/ <br />^Check # (0 olea <br /> Cash <br /> UST-CAP Site Local HW Cleanup Site. <br /> non-NPL/SEP 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 —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br /> Acute Care <br /> Veterinary Clinic