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0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br /> License # Capacity Vehicle # <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (#01 Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />r _. <br />- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />:New EH Pro ram and New Facilit <br />Program Record ID go5-4-is <br />C-17 -k((AN 5 NVOR0 A,„/N Coo <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) LTH <br />L t-A -7- INF <br />Food Handlers Course required: YES 0 No 0 <br />I:Vending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit— Make Vehicle Type <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 />Grade A Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility <br />Hazardous Waste Generator (2200) -->-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel ----Number of Units <br />Employee Housing (2700) Use Employee Housincaabor 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 <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm—Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Transfer Station <br />Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use P WS E HD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 1)-Ari\ e1\ Day Ph 'TS'OR P (12(0(-1. Night <br />0 New EH Program at Existing Facility <br />Facilit IDJo2-7'?77 <br />PAY WN7- <br />• E-cs Oa, n <br />6 202? <br />sAN J o4Q <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Color <br />Sticker # <br />Color <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />Ci Program 3 Facility <br />0 PBR (2231) 0 PBR HHW (2236) <br />0 Jail or Exempt Institution —Number of Units <br />UIC Site <br />Landfill <br />Waste Tire Facility <br />0 Limited Hauler <br />0 > 60 generators <br />Ph gb1S (t 2(o9 <br /> <br />PROGRA E LEMENT (30 FEE <br />cs- AMOUNT PAID .6 -- 7-6() <br />ERMIT VALID2 <br />r Date <br /> <br />REVIEWED BY ACCOUNTING OFFICE <br />/73o57/07 <br />Facility Address 1--1 1 n e <br />MASTERFILE RECORD INFORMATION PINK <br />INSPECTOR # <br />Check # <br />Cash <br />0 Surcharge FEE 0 Other FEE <br />to \ -S1- 2 0 Food Handler <br />INVOICE # 324 <br />Date / 2.3