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New EH Program at Existing Facility DNew EH Program and New Facility <br />Facility ID Program Record ID ?POS----/it ti/2T <br /> <br />SAN JOAQUIN COUNTY E 'RONMENTAL HEALTH DEPAR' 7.NT <br />MASTERFILE RECORD INFORMATION FORM <br />CI Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />DI Dumpsters > 20 cu yd (# of Units) <br />0 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />NmENTAL <br />PAYMENT <br />JUN <br />HEA0R:DCENED <br />02 2017 <br />SAN JOAQU N ENVIR0 I - COUNTy <br />EPARNENT <br />Lcnd <br />Registration # A Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />CI Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />5 13 LT E- a 6-1,3-i-7 D_ <br />CI Grade B Dairy Cl Milk Dispenser-Number of Containers in Multi-Head Unit <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool CI Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Cl Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station <br />CI Waste Tire Facility 0 Compost Facility <br />CI Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />GI Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 0 11 -60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />-P <br />oLu c ,g7ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph --X-0 ie. LA Night Ph I <br />I <br />(Please check the appropriate description and specify size, ninber of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Cl Commissary 0 Dry storage only <br /> <br />CI Retail Market----Square footage <br />Square Footage <br />CI with Food Preparation <br />El w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />License # <br />Facility Address ).-)C/DD L3 <br />Food Handlers Course required: YES Si-- No El <br />DVending Machines Number of Units <br />0 Multiple Departments CI Prepackaged Goods Only <br />Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Kennel <br />License # Capacity Vehicle # <br />Cl Package Treatment Plant CI Chemical Toilets ----Number of Units <br /> <br />PROGRAM ELEMENT FEE c- <br />INSPECTOR # (-6 `I CI6 / PERMIT VALID <br />0 Check # r4S-113 AMOUNT PAI <br />Cash REVIEWED BY <br />CI Surcharge FEE <br /> <br />to 5/ /7 CI Food Handler <br />Date INvoicE# 02-q 01711 <br /> <br />ACCOUNTING OFFICE ( if Date s_5"--- <br />CI Other FEE <br />48-02-034 MASTERFILE R CO INFORMATION PINK <br />1/23/13