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1ENT <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> PBR HHW (2236) <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />/ <br />J- <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 />__ to <br />~7//7 II t <br /> License # <br /> Package Treatment Plant <br />Program Element <br />Inspector# <br /> Check# <br /> Cash <br />48-02-034 <br />1/23/13 <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 /> Vehicle Type Color <br /> License# Sticker# <br /> VehicleType Color <br /> License# Sticker# <br />g to Ice Plant Produce Stand <br />to d<P4 CFO A B <br />Day Ph <br />Fee Z52. DO Surcharge Fee <br />Permit Valid. _ to <br />Amount Paid ■ Date <br />Reviewed by Accounting Office <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) <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 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 VehicleRegistration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station Ag/Cannery Waste Site Sludge/Ash Site <br /> Waste Tire Facility Compost Facility Process/Recycle Facility CIA Landfill Site <br /> Refuse Vehicles (# of Units) Dumpsters > 20 cu yd (# of Units) Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator Small Generator Li^^eMia^Jbf ’kT <br /> Transfer Station Veterinary Clinic Common Storage Facility 2 - 10 11 - 60 > 60 genSfe^^f} <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form Jlj!_ 1 7 <br />1/ zv I / Emergency NoTiFrpATiON for this FACILITY and/or PROGRAM sak, <br />CONTACT PERSON jLDj S W I V V I (A Day Ph() 7/ / -Z^ fiight Ph CQ( <br />Fee Z52. DO □ Surcharge Fee □ Other FEE t <br /> Food Handler <br />_ Invoice #___________________ <br />Date -7//7//C 'V/T/ <br />MASTERFILE RECORD INFORMATION PINK <br />SAN JOAQUIN COUNTY VIRONMENTAL HEALTH DEPAF <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility_________________________PNew EH Program and New Facility <br />Facility ID Program Record ID II <br />Facility Address 1/7^ Pk7\//; <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- Make <br />Registration # <br /> Temporary Food Facility -Dates of operation from______ <br />^H^Special Event—Dates of operation from Qv|\|