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Color <br /># <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Natural Bathing Area Pool Spa Out of Service Pool/Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> 11 - 60 <br />MASTERFILE RECORD INFORMATION PINK <br />Check # <br />Cash <br />48-02-034 <br />11/15/07 <br />Tons Generated Per Year <br /> Silver Only (2222) <br /> Conditionally Authorized (CA) <br /> Permit-By-Ruie Fixed Unit <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 /> Ice Plant <br /> Produce Stand <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> Other Fee <br /> Food Handler <br />Invoice# j <br />Date <br /> License # <br /> Package Treatment Plant <br />/JF <br /> payment <br />PECEIVeq <br />SFP 2 3 2017 <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 ^\C>C)Program Record id <br />Facility Address FF-F A^(9Z47 (5A <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 />^JZ'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 />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation PVending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsP Prepackaged Goods Only <br /> Vehicle Type Color <br /> License # Sticker # <br />_ Vehicle Type Make <br />______ License # <br />P Recycle/Exempt System (2299) <br />P Appliance Recyclers (2217) <br />P Conditionally Exempt (CE) <br />P Permit-By-Rule Household Hazardous Waste <br />P 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 />P Hotel/Motel-----Number of Units P 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 />P Environmental Assessment P UST-CAP Site P Local HW Cleanup Site P NPL/SEP Cleanup Site P UIC Site <br />P Abandoned HW Site P non-NPL/SEP Cleanup Site P RWQCB Cleanup Site P Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br /> P Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />P Tattooing (4121) P Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />P Pumper Vehicle Registration # <br />P Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />P Landfill P Transfer Station <br />P Waste Tire Facility P Compost Facility <br />P Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />P Primary Care P Acute Care P Skilled Nursing P Large Generator P Small Generator P Limited Hauler <br />P Transfer Station P Veterinary Clinic P Common Storage Facility P 2 -10 P 11-60 P > 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 />CONTACT PERSON CfITii/" Dav Ph ZX-7) 3^3- /OzdNight Pf( V ZU <br />Program Element _ ___7 Fee _______ P Surchi <br /> Inspector# 7- Permit Va^D ' to- <br />(P Check # /Amount PAici/> Date <br />P Cash Reviewed by Accounting Office