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SEP 2 7 2023 <br />I <br /> Grade B Dairy Milk Dispenser-Number of Containers in MulU-Head Unit _ <br /> Program 3 Facility <br />e <br /> Spa Out of Service Pool/Spa Natural Bathing Area <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 /> Capacity Vehicle #. <br /> Chemical Toilets —Number of Units <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Number of chemicals: <br /> Program 2 Facility <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />Square Footage _________ Food Handlers Course required: Yes No <br /> with Food Preparatton OVending 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 />License # <br /> Package Treatment Plant <br />162, / <br />ACCdUNTlI <br />Program Element <br />Inspector # 4589 <br /> Check# <br /> Cash <br />48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM____ <br /> New EH Program at Existing Facility ENew EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address FVnh ) 2S (Ntyi .Si I <br />(Ptease check the appropnate description and speafy size, number of units and pertinent information) <br />SRAM (1600) <br /> Restaurant Seating Capacity <br /> Commissary Dry storage only <br />O 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 to <br />Ki-Special Event—Dates of operation from tc| iCA^to <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) <br /> Cal ARP 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-----Number of Units Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Fonv <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-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Pool <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 />□QUID WASTE PROGRAM (4200) <br />□ Pumper Vehicle Registration# <br /> Pumper Yard <br />SOUP 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 □11-60 □>60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonv <br />Emergency Notification for this FACILITY and/or PROGRAM n rp- fr-r/ <br />CONTACT PERSON MS DayPh C/S? Night Ph f S3 / <br />1695 pEE 162 ______ Surcharge/FEE Other FEE <br /> Permit Valid ~ to /(y □ Food Handler <br />___ Amount Paid Date Invoice# z <br />Reviewed by Acc6unting Office / _________Date 12X7'2^____________ <br />'■ masterfile record information pink