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PROGRAM ELEMENT / FEE t <br />INSPECTOR # Mcfai ,ek_ PERMIT VALID <br />gi <br />7 1 check # ,3 / AMOUNT PAID _5 <br />Cash REVIEWED BY <br />El Surchar e F <br />to 5-3 / <br />Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />0 Food Handler <br />INvoicE # 38/p2,/ <br />Date 5523 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existin Facility <br />içJ <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />,g1 Restaurant: Seating Capacity PI Square Footage Food Handlers Course required: YES M No 0 <br />CI Commissary 0 Dry storage only El with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />CI Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />CI Hazardous Materials Business Plan (1900) Number of chemicals. <br />El CalARP Program Cl Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />El Hazardous Waste Generator (2200) > - Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235 2237) CI PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units CI 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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site El RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration t/ License # Capacity Vehicle # <br />CI Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station El Ag/Cannery Waste Site CI Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (t/ of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 El 11 - 60 El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOT/IFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON eL_TY.e.` "C L- Day 57LiC))i .7 Night Ph çQI <br />48-02-034 MASTERFILE RECORD IN ORMATION PINK <br />1/23/13 <br />OK -I-, perri,1 <br />Facility ID F-4(YD2 -7,7:2 <br />Facility Address I 2 7 <br />ElNew EH Pro ram and New Facility <br />Program Record ID K_(.5- <br />,.1 -1 e <br />MAY <br />RECI <br />PAYmE NT <br />03 2023 <br />VED <br />SAN JoA Q , <br />1.4 EN OR 0 iVroIRIECN7_4 <br />..EALTH D"AfTMENT