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(ENT'IRONMENTAL HEALTH DEPAF <br />ColorMake <br />License # <br />to <br />to <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br />MASTERFILE RECORD INFORMATION PINK <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 />__ Ice Plant <br /> Produce Stand <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY <br />MASTERFILE RECORD INFORMATION FORM <br />PNew EH Program and New Facility <br />Program Record ID <br /> Milk Dispenser-Number of Containers in Multi-Head Unit. <br /> Hazardous Materials Business Plan (1920,1921) <br /> License # <br /> Package Treatment Plant <br />Tons Generated Per Year Recycle/Exempt System (2299) <br /> Silver Only (2222) Appliance Recyclers (2217) <br /> Conditionally Authorized (CA) Conditionally Exempt (CE) <br /> Permit-By-Rule Household Haz Waste <br />23/5 <br />JC16r\ <br />- ' ■ .... ............................................................................................................................................................................................................................................................ <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending Machines Number of Units <br /> with Meat Market only Multiple DepartmentsP Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type <br />Sticker # <br />3 /1 7 p <br />P New EH Program at Existing Facility <br />Facility ID <br />Facility Address <br /> Small Generator Limited Hauler <br />P 11 - 60 P > 60 generators <br />W / 2 <br />JO/ - <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />P Restaurant: Seating Capacity <br />P Commissary P Dry storage only <br />P Retail Market—Square footage <br />P Mobile Food Vehicle -Make <br />Registration # <br />P Mobile Food Prep Unit <br />Registration # . <br />ETTemporary Food Facility -Dates of operation from 3 p 6 [ I I <br />P Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br />P Grade A Dairy P Grade B Dairy <br />CUPA P Hazardous Materials Program (1900) <br />Hazardous Waste Program (2200) <br />P Hazardous Waste Generator------ <br />P CRT Offsite Handlers (2218)------------- <br />P Tiered Permitting Facility----------------- <br />Pay Ph Ph <br />P Surcharge Fee P Other Fee <br />to P Food Handler <br />Date Invoice# <br />Accounting Office Date <br />P Permit-By-Rule Fixed Unit <br />P Aboveground Storage Tank Facility (AST) (2390) Number of AST <br />P Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />P Hotel/Motel-----Number of Units P 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 />P Environmental Assessment P UST-CAP Site P Local HW Cleanup Site P NPL/SEP Cleanup Site P UIC Site <br />P Abandoned HW Site P non-NPL/SEP Cleanup Site P RWQCB Cleanup Site P Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility P Pool <br />VECTOR CONTROL PROGRAM (4000) <br />P Poultry Farm-------Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />P Body Art Practitioner Reg (4110) P Mechanical DSPS Notification (4115) P Body Art Facility-Single Use (4120) <br />P Body Art Facility-Sterilization (4121) P Body Art Temp Event Co-ord (4130) P Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />P Pumper VehicleRegistration # <br />P Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />P Landfill P Transfer Station <br />P Waste Tire Facility P Compost Facility <br />P Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br />P Transfer Station P Veterinary Clinic P Common Storage Facility P 2 -10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 4^-02-003 Blue Application Form <br />~~ /EMERGEyfY NotiRMZATfoN for this FACILITY and/or PROGRAM-Z' <br />CONTACT PERSON^TxIZ7 -------Dav Ph 7 .4/T/^^Night <br />Program Element Fee__J E \ P?^2 <br />Inspector# | Permit Valid <br />P check# Amount Paid J.ifD <br />P Cash R EVIEWED BY <br />48-02-034 <br />8/21/12