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<br />■f=- <br />to Oct. 31,2023 <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Spa Natural Bathing Area <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />7W <br /> Capacity Vehicle #. <br /> Chemical Toilets—Number of Units <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending Machines Number of Units <br /> w/Meat Market only Multiple Departments Prepackaged Goods Only <br /> Color <br />_ Sticker # <br /> Color <br />_ Sticker # <br />!____ Ice Plant Produce Stand <br /> CFO A 8 <br /> Out of Service Pool/Spa <br /> License # <br /> Package Treatment Plant <br />Night Ph <br />_ □ Other Fee I <br />_ □ Food Handler I <br />_ Invoice # | <br /> Date [ <br />MASTERFILE RECORD Ih/FORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM________ __ <br />^-^.ew EH Program at Existing Facility___________________ ^frlew EH Program and New Facility <br />| Facility ID ' _______________Program Record ID -p££) S Id)— <br />Facility Address Legacy Fields - 4901 N. Tracy Blvd., Tracy, CA 95304 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br /> Commissary Dry storage only <br /> Retail Market—Square footage <br /> Mobile Food Vehicle-Make Vehicle Type <br />Registration# License# <br /> Mobile Food Prep Unit- Make Vehicle Type <br />Registration #License # J <br />E Temporary Food Facility -Dates of operation from Sept. 1,2023 <br /> Special Event—Dates of operation from to <br />fee exew <br />Permit Valid \ - 21 <br /> Amount Paid 6~ <br />Reviewed by Ai <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 Program 3 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 USTA and B forms <br /> Other CUPA Program ' ________________________________ <br />HOUSING PROGRAM (2400) <br /> Hotel/Motel Number of Units Jail or Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPUSEP 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 /> Body 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 Vehicle Registration # <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 /> Transfer Station Veterinary Clinic Common Storage Facility 0 2-10 11 - 60 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />□o+riMiz ...^ERGENCY Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON HaulcK Manning Day Ph lb lU) ou <br />PROGRAM Element \kfls FEE □ Surcharge Fee <br />I inspector# V1L- Permit Valid to (Q-3><- 2S <br />J Check #_____________ Amount Paid 6TDate <br />| □ Cash Reviewed by____________~ Acxounting Office <br />48-02-034 <br />1/23/13