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to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Natural Bathing Area Pool Spa Out of Service Pool/Spa <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br />CONTACT PERSON, <br />6 <br />Number of chemicals: <br /> Program 2 Facility <br /> Ag/Cannery Waste Site <br /> Process/Recycie Facility <br /> Dumpsters > 20 cu yd (# of Units) <br /> Capacity Vehicle # <br /> Chemical Toilets-—NumberofUnits <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> to s n opto <br /> License #. <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVendlng 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 Ptant Produce Stand <br /> CFO A B <br /> Surcharge Fee <br />. to ylojl^ <br />Date ' %/ <br />Accounting Office ZL//0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM ___ <br />^j^New EH Program at Existing Facility DNew EH Program and New Facility <br />| Facility ID Program Record ID <br />Facility Address'VHonrVxrCt PlCOQ - lefe <br />(Please check (he 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 />Regislration # <br /> Temporary Food Facility -Dates of operation from ____ <br />^Special Event—Dates of operation from | IQ j 1 kj <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)----------> 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 /> Hotel/Motel-----Numberof 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 NPUSEP 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 <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 VehicIeRegistration# <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (HofUniis) <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 Form <br />. .Emergency Notification for this FACILITY and/or PROGRAM <br />_ c hlYegni Day Ph<5lC^g?A- Night Ph ^09 -fr "Ul <br /> PROGRAM Element Fee<^7,=)9. □ Surcharge Fee________ □ Other FEE______________ <br />Inspector# PermitVal)d 3/loh^ to □ Food Handler <br /> check# — Amount Paid Date Invoice # <br /> Cash Reviewed by Accounting Office Date <br />48-02-034 ’ ~ “ ~~ MASTERFILE RECORJi INFORMATION PINK <br />1/23/13