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07/1110./08/2018 PAGE22:48 2093335599 LAS <br />ColorMake <br />License # <br /> Milk Dispenser-Number of Containers in Multi-Head Unit ____ <br /> Natural Bathing Area Spa Out of Service Pool/Spa Pool <br /> Kennel <br />O Permanent Cosmetics (4122) <br /> Skilled Nursing Large Generator <br /> 11-60 <br />MASTERFILE RECORD INFORMATION PINK <br /> Capacity ■ Vehicle# <br /> Chemical Toilets —Number of Units <br /> Ice Plant <br /> Produce Stand <br />Received Time Oct, 9. 2018 10:24AM No. 4246 <br />11/15/07 <br />-Tons Generated Per Year <br />-□ Silver Only (2222) <br />-□ Conditionally Authorized (CA) <br /> Permit-By-Rule Fixed Unit <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd of Units) <br /> Sludge/Ash Site <br /> CIA Landfill Site <br /> Farm/Ranch Cleanup Site <br />____ to <br />to <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation nVending Machines Number of Units <br /> with Meat Market only Multiple Departments Prepackaged Goods Only <br /> Vehicle Type Color <br /> License# Sticker# <br />Vehicle Type <br /> Sticker # <br />..urge Fee_____ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPArxl'MENT <br />MASTERFILE RECORD INFORMATION FORM________________________ <br /> New EH Program at Existing Facility "XlNew EH Program and New Facility <br />Facility ID Program Record ID <br />Fa ci I ity Ad d ress __________ <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—Mak© <br />Registration # <br /> Mobile Food Prep Unit <br />Registration # <br /> Temporary Food Facility -Dates of operation from <br />Special Event Dates of operation from Z^ ° <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dairy <br />CUPA State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br /> Hazardous Waste Generator' <br /> CRT Offsite Handlers (2218) - <br />Tierod Permitting Facility --------- <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 /> HoteUMotel------Number of Units Jail or Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Hoysinq/LebQr 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 <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 VehlcleReglstration # <br />O 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 Small Generator Limited Hauler <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 ni1-60 □> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Emergency Notification for this FACILITY and/or PROGRAM <br />CONTACT PERSON Z7 ■ Day Night Ph <br />Program Element 11 Fee . L-rx^f' □ Surcharge Pep □ other Fee <br />Inspector # c<s ') T# Permit Valid to □ Food Handler <br /> check# Amount Paid Date Invoice# <br /> Cash Reviewed by Accounting Office Date