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4. 2016 4:26PM P. 3/3No. 2855 <br />•NT <br />ColorMake <br />to <br /> Milk Dispenser -Number of Containers in Multi-Head Unit <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br />O Kennel <br /> Permanent Cosmetics (4122) <br /> Acute Care <br />MASTERFILE RECORD INFORMATION PINK <br />Fee_ <br />Permit Valid <br />Ami <br />Reviewed by L <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 />d Produce Stand <br /> Recycle/Exempt System (2299) <br /> Appliance Recyclers (2217) <br />O Conditionally Exempt (CE) <br /> Permit-By-Rule Household Hazardous Waste <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />IT Paid <br />)____ <br />License # <br />03/n/|^ <br />to <br />Program Element <br />Inspector# <br /> Check# . <br />| D Cash <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVendlng Machines Number of Units <br /> with Meat Market only Multiple Departmentsd Prepackaged Goods Only <br /> Vehicle Type __ ________ Color <br /> License # Sticker # <br />Vehicle Type <br />Sticker # <br /> Small Generator Limited Hauler <br /> 11 - 60 > 60 generators <br /> New EH Program at Existing Facility ^New EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address <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 <br />Registration # <br />^-Temporary Food Facility -Dates of operation from <br /> Special Event Dates of operation from <br />□AIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy <br />CUBA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator-—- <br /> CRT Offsite Handlers (2218) -—— <br />Tiered Permitting Facility--------------- <br />Mar. 4. 201 6, 4:26PM GHIRARDELLI <br />SAN JOAQUIN COUNTY L .RONMENTAL HEALTH DEPART <br />_________________MASTERFILE RECORD INFORMATION I^ORIVI______________ <br />________^New EH Program and New Facility <br />Program Record ID <br />-Tons Generated Per Year <br />-□ Silver Only (2222) <br />-□ Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <br /> ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USfA and B forms <br />HOUSING PROGRAM (2400) <br />O Hotel/Motel------Number of Units Q Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housiriq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site 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 (3500) <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 />O Tattooing (4121) Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper VehicleRegistration # <br /> Pumper Yard <br />SOLID 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 <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 />n. . -^-Emergency Notification for this FACILITY and/or PROGRAM CONTACT PERSON IWlA < iv/Z/S Day Ph 3/2// Night Ph <br />(£7*3 FEE Surcharge FEE D Other FEE <br />Permit Valid to Food Handler <br />—__ Amount Paid Date ''-7 7 Invoice# <br />Accounting Office Date <br />Received Time Mar. 4. 2016 4:27 PM No. 0541