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SAN JOAQUIN COUNTY 2NT <br />Make Color <br />License # <br />$// 7/3 to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Natural Bathing Area Spa Out of Service Pool/Spa Pool <br /> Kennel <br /> 11-60 <br />CONTACT PERSON <br />MASTERFILE RECORD INFORMATION PINK <br /> Ice Plant <br /> Produce Stand <br />48-02-034 <br />8/02/12 <br />Program Element <br />Inspector# <br /> Check #_ <br /> Cash <br /> Capacity Vehicle# <br /> Chemical Toilets —Number of Units <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <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 /> to ____ <br />»//7^ <br />Day Ph 7cfl. Night Ph <br /> Other Fee <br /> Food Handler <br />Invoice# <br />Date <br /> License # <br /> Package Treatment Plant <br />Square Footage 76'0 Food Handlers Course required: Yes No <br /> with Food Preparation Vending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsO Prepackaged Goods Only <br /> Vehicle Type Color <br /> License # Sticker # <br />Vehicle Type <br /> Sticker # <br />li //3 <br />A IkUNMLN I.AL IIEALTH DEPAR <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ______ XlNew EH Program and New Facility <br />Facility ID Program Record ID | <br />Facility Address 7'777^ /A7ay . 7?^ <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 <br />Registration # <br /> Mobile Food Prep Unit <br />Registration # <br /> Temporary Food Facility -Dates of operation from <br />S Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy <br />CUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator <br /> CRT Offsite Handlers (2218) - <br />Tiered Permitting Facility--------- <br />Tons Generated Per Year <br /> Silver Only (2222) <br /> Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use L/ST A and B forms <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-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <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 □2-10 Dll-60 □>60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />_ Emergency Notification for this FACILITY and/or PROGRAM <br />_ Fee_ <br />Permit Valid <br />Amount Paid _ <br />Reviewed by <br /> Surcharge Fee <br />to #7/ 7/3 <br />, Date <br />Accounting Office <br />izs P <br />ement <br />V