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i <br />ColorMake <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit------ <br /> Natural Bathing Area Out of Service Pool/Spa Spa Pool <br /> Kennel <br /> Permanent Cosmetics (4122) <br />£ <br /> Skilled Nursing Large Generator <br /> 11 -60 <br />CONTACT PERSON <br />masterfile record INFORMATION PINK <br />Program Element <br />Inspector# <br /> Check# . <br /> Cash <br />48-02-034 <br />11/15/07 <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Ice Plant <br /> Produce Stand <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) <br />License # <br /> Package Treatment Plant <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup She <br />_ License # <br />u <br />7 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM_____________________ <br /> New EH Program at Existing Facility _____________DNew EH Program and New Facility <br />| Facility ID Program Record ID ___J <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) . . Restaurant Seating Capacity Square Footage------------------ Food Handlers Course reguir^ <br /> Commissary Dry storage only with Food Preparation DVending Machines Number of Units <br /> Retail Market—Square footage L <br /> Mobile Food Vehicle -Make _— Registration # <br /> Mobile Food Prep Unit _ _______1 <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 Offeite Handlers (2218)------- <br />Tiered Permitting Facility-------------- <br />Capacity Vehicle# <br /> Chemical Toilets —Number of Units--------- <br />Fro /VE° <br />Square Footage Food Handlers course requireg: Yes <br /> with Food Preparation DVending Machines Number of Units -------------- <br /> with Meat Market only Multiple DepartmentsO Prepackaged Goods Oniy VehicleType _ ______ Color _____________License #Sticker # <br /> Vehicle Type <br /> Sticker# <br /> Recycle/Exempt System (22991 <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B fornis <br /> HOUSING PROGRAM (2400) jail or Exempt Institution—Number of Units--------------- Hotel/Motel------Number of Units c <br /> Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />p V ,^nnn\ UNDERGROUND INJECTION CONTROL (3000) SITE MITIGATION (2900) UST-CAP Site Local HW Cleanup Site NPUSEP Cleanup Site nuiCSrte <br />□ Atando^Hwlte □ 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 />LIQUID WASTE PROGRAM_(42QO) <br /> Pumper Vehicle Registration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill n Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of Units)----------- <br /> <br /> <br /> <br /> W-— PERmVALm <br /> AMOUNT PAID Date—^7 — <br />Reviewed by__________________Accounts Office-------------------------------------------------