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iL^ <br />to <br />to <br /> Milk Dispenser-Number of Containers in Multi-Head Unit------- <br /> Natural Bathing Area Out of Service Pool/Spa Spa <br /> Kennel <br /> Permanent Cosmetics (4122) <br /> 11-60 <br />CONTACT PERSON <br />MASTERFILE RECORD INFORMATION PINK48-02-034 <br />f 1/15/07 <br /> License # <br /> Package Treatment Plant <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# at Units) <br /> Ice Plant <br /> Produce Stand <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br /> harge Fee <br />ISE <br />loo <br />' S/Zz/^2- <br />fr-Vr <br /> Capacity Vehicle # <br /> Chemical Toilets —Number of Units <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />L MASTERFILE RECORD INFORMATION FORM <br />Ej New EH Program at Existing Focillty DNew EH Program and New FacHjt)/ <br />[facility ID Program Record ID ^77I <br />Facility Address notab N- Trtck TonJC ^240 <br />(Please check the appropriate description and specify size, number of units and pertinent information ) <br />EQQP PROGRAM (1600) <br /> Restaurant Seating Capacity <br /> Commissary Dry storage only <br /> Retail Market—Square footage <br />EJ Mobile Food Vehicle -Make 4- < J <br />S^A/ <br />Square Footage __________ Food Handlers Course required; Yes No l_ <br /> with Food Preparation DVcnding Machines Number of Units---------------- <br />_ with Meat Market only Multiple DepartmentsD Prepackaged Goods Only <br />Mobile Food Vehicle -Make 7-^ U <2. c* _________ Vehicle Type (3oa TY~U<-fe=------- Color — <br />Registration# TaLP,H vU'17 3bVQooqzLicense# tJ Z--------- Sticker# c^ooS 4 <br /> Mobile Food Prep'unlt Make f Vehicle Type---------------------------Color <br />Registration #License # Sticker #------------------------------ <br /> Temporary Food Facility -Dates of operation from <br />□ Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy <br />PUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator-------------Tons Generated Per Year <br /> CRT Offsite Handlers (2218)-------------- Silver Only (2222) <br />Tiered Permitting Facility —------------- -—O Condrtionally Authorized (CA) <br /> Permil-By-Rule Fixed Unit <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br /> Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br /> Hotel/Motel------Number of Units JaH or Exempt Institution —Number of Units---------------- <br />Employee Housing (2700) Use Employee Housina/Lnbor 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-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 /> Tattooing (4121) Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper VehlcIeRegistration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (« of Unite) <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 />Ehergenc;y notification for this FACILITY and/or PROGRAM / <br />ScaJI __ DayPh(Zc)4)7V^^ZZ Night Ph (2<>\ z 7 / <br /> Program Element Fee ( ------- Surcharge Fee Other Fee------------------------- <br /> <br /> Inspector# Permit Vaud 3^/^- to------- D Food Handler-------------- <br />□ check * Amount Paid Date 5/7 ------- Invoice# . >-----------— <br /> cash Reviewed by Accounting Office _ Date <br />V/<,^