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Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Local HW Cleanup Site <br /> Spa Out of Service Pool/Spa Natural Bathing Area <br />I-] Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <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 />Fee _ <br />Permit Valid <br />Amount Paid <br />Reviewed by <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />CONTACT PERSON <br />Program Element <br />Inspector# <br /> Check # <br /> Cash <br />48-02-034 <br />1/23/13 <br />t° « <br />4^ <br /> License # <br /> Package Treatment Plant <br />iD, | <br />-------------------—J <br />Food Handlers Course required: Yes No <br />□Vending Machines Number of Units <br />' Multiple Departments Prepackaged Goods Only <br />_ Color <br /> Sticker # <br />____ Color <br />i j Sticker # <br />- / l& / 2^ 3 *ce p,ant O Produce Stand// I CF0 n A D 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />I-----— MASTERFILE RECORD INFORMATION FORM <br />□ New EH Program at Existing Facility Dnsw EH Program and New Facility <br />I Facility ID Program Record ID <br />Facility Address C I-A <br />(Please check the appropriate description and specify size, number of units and pertinent information ) <br />FOOD PROGRAM (1600) --------'' <br /> Restaurant: Seating Capacity Square Footage <br />□, Commissary Dry storage only with Food Preparation <br />,-^Retail Market-Square footage /.(/ XJ-C? w/Meat Market only <br /> Mobile Food Vehicle -Make _____________ Vehicle Type <br />Registration #____________License # <br /> Mobile Food Prep Unit- Make ________ Vehicle Type~ <br />y. Registration #License # <br />^Temporary Food Facility -Dates of operation from 9 ///; / Z "b <br />y^LSpecial Event—Dates of operation from <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) Number of chemicals: <br /> CalARP Program □ Program 1 Facility □ Program 2 Facility <br /> Hazardous Waste Generator (2200) —->-Tons Generated Per Year <br />□ Tiered Permitting Facility-> □CA(2232) □ CE (2233. 2234. 2235, 2237) □PBR(2231) 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 />' »0,el OfcUnlt? —n n Ja" or ExemP‘ Institution -.Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br /> gjJE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />LJ Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br />□ Abandoned HW Site □ non-NPL/SEP Cleanup Site RWQCB Cleanup Site □ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 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) □ Mechanical DSPS Notification (4115) □ Body Art Facility-Single Use (4120) <br />ody Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper VehicleRegistration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />□ Primary Care □ Acute Care □ Skilled Nursing □ Large Generator □ Small Generator □ Limited Hauler <br />U Transfer Station Veterinary Clinic Common Storage Facility □2-10 11 - 60 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM. (4600) Use PWS EHD 46-02-003 Blue Application Fonn <br />Emergency Notification for this FACILITY and/or PROGRAM <br />—pay Ph. Night Ph <br /> Surcharge Fee Other Fee <br />------------------- to .. Food Handler <br /> Date Invoice#_______________ <br />Accounting Office Date <br />MASTERFILE RECORD^NF^RMATldlTprNfr