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Other FEE <br />Food Handler <br />INvacE # o SO <br />Date <br />PAymENT Receiver, <br />MAY 2 5 2018 <br />SAN JOAQUIN <br />COUNTY ENV/RON <br />MENTAL HEALTH <br />DEPARTMENT <br />ommissary 0 Dry storage only 0 with Food Preparation OVendIng Machines Number of Units <br />Make <br />License # <br />Sticker # <br />to 0 ice Plant <br />RECREATIONAL HEALTH PROGRAM (3600) <br />0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />HOUSING PROGRAM (2400) <br />Employee Housing (2700) Use Employee Houana/Labor Camp Application Form <br />0 Hotel/Motel —Number of Units 0 Jall or Exempt institution --Number of Units <br />ITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CUPA 0 State Facility Surcharge (2399) <br />PAIBLE.R.S226AM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 CRT Offsite Handlers (2218) -----------D Silver Only (2222) 0 Appliance Recyclers (2217) <br />0 Hazardous Waste Generator —Tons Generated Per Year 0 Recycle/Exempt System (2299) <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br /> to 0 Produce Stand <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm -----M aximum number of birds <br />0 Kennel <br />0 Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Small Generator 0 Limited Hauler <br />11 - 80 0 > 60 generators <br />OENCY NOTIFICATION FOR THIS FACILITY AND/OR PRO CONTACT PERSON \ claii,q,c tAy- <br />GRAM <br />Day Ph An ---2 0 3-Sa3c Night Ph <br />PROGRAM ELEMENT \ V...)-:. L- FEE 0/1. OD 0 Surcharge FEE INSPECTOR # PERMIT VALID to I'L -31 i ri Check # AMOUNT PAID Date <br />0 Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 <br /> 6x-7 4 4(736 <br />11/15/07 MA8TERFILE RECORD INFORMATION PINK <br /> <br />L_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Prom at ExistIn Fa Ility <br />Fadlit ID <br />FA °C))-- ram Pro <br />Facility Address 3:-Ac) \1. 1\J (1.1 e-c 71-00/ 015-3 61-1 <br />(Please check the appropriate description and sp'ecIfy. Alm Dumber of unl and pertinent Information.) EQQapagaagm_ (1600) <br />U Restaurant. Seating Capacity Square Footage 0 <br />Retail Market—Square footage <br /> <br />Registration # <br /> <br />Mobile Food Vehicle —Make <br />LI Mobile Food Prep Unit <br /> <br />Registration # <br />0 Temporary Food Facility —Dates of operation from <br />0 Special Event Dates of operation from <br />with Meat Market only <br />Vehicle Type <br />License # <br />ecord ID <br />New EH Program and New Facility <br />0 Multiple Departments0 Prepackaged Goods Only <br />Color -7) 't \ -72) Sticker # <br /> Vehicle Type Color <br />Food Handlers Course required: YES 0 No 0 <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />0 Waste Tire Facility 0 Compost Facility 0 Refuse Vehicles (ti of Units) <br />MEDICAL_WASTE PROGRAM (4500) 0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 Ejazzgaftzusapiagaged (4600) Use pws END 46-02-003 Blue ADDIkaflon Form <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) 0 Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number of Units <br />0 Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (t$ or units)