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MENT <br />pj • <br /> Milk Dispenser-Number of Containers in Multi-Head Unit Grade B Dairy <br /> Program 3 Facility <br /> Natural Bathing Area Spa Out of Service Pool/Spa Pool <br /> Kennel <br /> Skilled Nursing Large Generator <br /> 11-60 <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />Number of chemicals: <br /> Program 2 Facility <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> License # <br /> Package Treatment Plant <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 /> Vehicle Type Color <br />License # _______Sticker # <br />tLQl'S to (S' Ice Plant Produce Stand <br /> to CFO A B <br /> Capacity Vehicle# <br /> Chemical Toilets —Number of Units <br />rms rMC/iLi i lwuiuk rRuurxHm .DayPhf^) ^l5«5^f6iightPh $Z0 <br /> Surcharge Fee Other Fee <br />to 11 y" □ Food Handler <br />130.D'P Invoice#________ <br />Accounting Office •^Z-Date Z/ / y <br />MASTERFILE RECORt) INFORMATION PINK <br />SAN JOAQUIN COUNTS IVIRONMENTAL HEALTH DEP/ <br />MASTERFILE RECORD INFORMATION FORM <br />□ New EH Program at Existing Facility |^lew EH Program and New Facility <br />| Facility ID ("TV O O Program Record ID Ip <br />Facility Address PhfFpF f'r , ~ <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 MzcU <br />'^.Special Event—Dates of operation from <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 payment <br /> Tiered Permitting Facility-------> ncA(2232) CE (2233, 2234, 2235, 2237) PER (2231) <br /> Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> Underground Storage Tank Program (UST) (2300) Use UST A and 5 forms Q g 2015 <br /> Other CUPA Program---------------------------------------------------------------------------------------------- SAN JOAQUIN COinu-r~ <br />HOUSING PROGRAM (2400) HEAI TV'n°MENTAL <br /> Hotel/Motel-----Number of Units Jail or Exempt Institution ----Number (^MiMtPEPART^^p <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 <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 Dll-60 □> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITXand/or PROGRAM / <br />CONTACT PERSON <J 6 j f, — <br />Program Element ______Fee _________ <br />Inspector# p7 '^-PermitValid (l <br />z^fcheck # Amount Paid _ <br /> Cash Reviewed by /\ <br />48-02-034 <br />1/23/13