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Io <br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Natural Bathing Area Spa Out of Service Pool/Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11 - 60 <br />Number of chemicals: <br /> Program 2 Facility <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 /> SludgelAsh Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />_________________MASTERFILE RECORD INFORMATION FORM______________ <br /> New EH Program al Existing Facility <br />| Facility ID <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent infomiation ) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br />KT Commissary S' Dry storage only <br /> Retail Market—-Square footage <br /> Mobile Food Vehicle -Make <br />Registration # <br /> Mobile Food Prep Unit— Make <br />Registration # <br /> Temporary Food Facility —Dates of operation from <br /> Special Event—Dates of operation from <br />Square Footage Food Handlers Course required: YesTS^NoD <br />55 with Food Preparation ClVending Machines Number of Units <br /> w/Meat Market only Multiple Departments Prepackaged Goods Only <br /> Vehicle Type Color <br /> License# Sticker# <br /> Vehicle Type Color <br />__________________ License# Sticker# <br /> Ice Plant Produce Stand <br /> CFO A B <br />________________________________________ENew EH Program and New Facility <br />Program Record ID I <br />ziod fAHLMwr pfir Central and 6 street, Tracy <br />Day Ph ^^53 Night Ph <br /> Other FEE <br />_ Food Handler <br />_ Invoice# / /____________ <br />Date <br />MASTERFILE RECORO INFORNIATION PINK <br />05 2023 <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) <br /> CalARP Program Program 1 Facility <br /> Hazardous Waste Generator (2200)-----------> -1 ons Generated Per Year <br /> Tiered Pennitting Facility--------> CA (2232) CE (2233, 2234, 2235, 2237) PBR (2231) PBR HHW (2230) <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 Unite 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 UST-CAP Site Local HW Cleanup Site NPUSEP Cleanup Site QUICSite <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 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 /> 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 Foim <br />Emergency Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON l/'IMfrEM-'-f TKOHAS <br />Program Element 1695 Fee 162 _______ □ surcharge Fi <br /> <br />Inspector # 4589_____ Permit Valid °]/ / /2..-^ to Il Cat <br />□ Check * V Amount PAid+p / 2 /Ot) Date <br /> Gash Reviewed by AccouhrriNG Office <br />40-02-034 A i <br />W / WT747