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IENT <br />T <br />Make Color <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> Skilled Nursing Large Generator <br /> 11-60 <br />CONTACT PERSON <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />11/15/07 <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of units) <br />Capacity Vehicle# <br /> Chemical Toilets —Number of Units <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />__ Ice Plant <br /> Produce Stand <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsQ Prepackaged Goods Only <br /> Vehicle Type Color <br /> License #Sticker # <br />Vehicle Type <br />t Sticker # <br /> License # <br /> Package Treatment Plant <br /> PERMIT VALipy <br />Amount Paid St ZScZqg) <br />Reviewed by <br />_____5®®° <br />-I Program and New Facility IfI ^Jo ' ’ <br />and pertinent information.) <br /> New EH Program at Existing Facility <br />Facility ID <br />Facility Address <br />(Please check the appropriate description and specify size, number of tmits 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 # License # <br /> ^-Temporary Food Facility -Dates of operation frohr1^/-^^ <br />'□'Special Event Dates of operation from <<7 / '' J <br />□XlRY 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 Offeite Handlers (2218)------------- <br /> <br />Tiered Permitting Facility-------------------- <br />1 Night Ph <br />charge Fee Other Fee <br />_________ Food Handler <br />7________ Invoice# <br />' Date <br />■Tons Generated Per Year <br /> Silver Only (2222) <br /> Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <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 Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPUSEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation 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 />SOUP 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 Large Generator Small Generator Limited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 11 - 60 □>60 generators <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 />Program Element ‘s V FeeJp/SL?OSurcharge <br />Inspector# Q Permit VaUD v 7 to- <br />□ Check # 7_ Amount Paid Date <br /> Cash Reviewed by Accounting Office <br />SAN JOAQUIN COUNTV -.JVIRONMENTAL HEALTH DEPAR <br />_ ________________MASTERFILE RECORD INFORMATION FORM_________ <br />______________PNew EH Pr< <br />Program Record ID <br />31 A I /r FUAui.