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2016 <br />Make Color <br />License # <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Spa Out of Service Pooi/Spa Natural Bathing Area <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> Skilled Nursing Large Generator <br /> 11 - 60 <br />Fee <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />11/15/07 <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 /> Ice Plant <br /> Produce Stand <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Sludge/Ash Site <br /> CIA Landfill Site <br />D Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <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 DEPA.xfMENT <br />„ MASTERFILE RECORD INFORMATION FORM <br />^g±^LEHPl£a.aT,at Existing Facility PNew EH Progfam and New Facili <br />Lfability10 Program Record ID ~| <br />Facility Address fit nd -H a ^EfiMi^Lh^LTh <br />(Please check the appropriate description and specify size, number of units and pertinent information ) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br />O Commissary Dry storage only <br />O Retail Market—Square footage <br />D Mobile Food Vehicle-Make <br />Registration # <br /> Mobile Food Prep Unit <br />Registration #_ <br /> 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 Generator <br /> CRT Offsite Handlers (2218) - <br /> Tiered Permitting Facility-------- <br />Inspector# |(5S>^ <br /> Check # <br />O Cash <br />Emergency Notification for this FACILITY and/or PROGRAM <br />' Day Ph Night Ph <br />1 Surcharge, Fee Other FEE <br /> l^./\ (a to 5/v y/G □ Food Handler <br />r' Date Invoice # . <br />Accounting Office 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 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 /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation 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 VehicleRegistration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />O 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 DH-eO □>60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Emsrgency <br />CONTACT PERSON jPcfe C <br />Program Element, <br />ZU. I I <br />|_______ Permit Valid <br />________ Amount Paid _ <br />Reviewed ------