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<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 Pool <br /> Kennel <br />CONTACT PERSON <br />Program Element <br />Inspector # <br /> Ag/Cannery Waste Site <br /> Process/Recycie Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />to <br />10 112.-1^ I H <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility UNew EH Program and New Facility <br />Facility ID ______ Program Record ID <br />FacilityAddress <br /> License # <br /> Package Treatment Plant <br />—1 <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 />t^Special Event-Dates of operation from |0|l2-i3 H <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 /> Ice Plant Produce Stand <br /> CFO A B <br />C> "Is# I ‘f Food Handler <br />Z3S2Ji ^v°ice # <br />Date <br />== MASTERFILE RECORD INFORMATION PINK <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <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) E1PBR(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------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-CAPSite 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 0H2CUp»j-r <br />□ Body Art Facility-Sterilization (4121) □ Body Art Temp Event Co-ord (4130) □ Body Art-Temp Event Mot5?<HCaJff^m3l) <br />LIQUID WASTE PROGRAM (4200) RECEIVED <br /> Pumper VehicleRegistration # License# Capacity Vehicle # nnlQ <br /> Pumper Yard Package Treatment Plant Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) .cuxOUlN COUNTY <br /> Landfill Transfer Station Ag/Cannery Waste Site SludgS'^n^^^jjiENTAL <br />□ Waste Tire Facility □ Compost Facility □ Process/Recycie Facility □ CIA La^gJ{-^it©EPARTMENT <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 <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 <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 />Day Ph Night <br />FEE Surcharge Fee Other FEE <br /> <br />Inspector# - PermitValid Z--, to <br />□ Check# | Lb? Amount Paid Date <br /> Cash Reviewed by (i A/\ . Accounting Office <br />48-02-034 <br />1/23/13