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3032222510 fax 01.07:15 p.m. 08-27-2014 216 up, ar• LVII Iw. J7V1 1 . L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM I] New EH Program at Existing Facility XNew EH Program and New Facility Facility ?`7 Program Record IDP;E! '� IR2 Facility Address 10710 A Trinity Parkway,Stockton,CA 952 19 (Please check the appropriate description and specify sl- ze, number of units and pertinent Information.) FOOD PROGRAM(1600) 19 Restaurant seating capacity._ Square Footage Food Handlers Course reclulred: Yes® No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market--Square footage Q w/Meal Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registrallon# Llcense# - Sticker# ❑ Mobile Food Prep Unit--Make VeHiae Type Color Registration# License# Slicker# ❑ Temporary Food Facliity--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event--Dates of operation from to ❑ CFO ❑ A ❑ B 13AIRY PROGRAM(2000( ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Mulli-Head Unit_ CUPA ❑ Hazardous Materials Business Plan(1000) Number of chemicals: ❑ CaIARP Program Q Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility Q Hazardous Waste Generator(2200)--------> Tons Generated Per Year Q Tiered Permlfting Facility---> ❑ CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PER (2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number ofASTs ❑ Underground Storage Tank Program (UST)(2300) Use UST A and 13 forms ❑ Other COPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution--Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Applicatfon Forth SIVE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ N13LJSEP Cleanup Site Cl UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm----Maxlmvm number of birds ❑ Kennel TATTOO,900Y PIERCING.PERMANENT COSMETIC PROGRAM(4100) Q Body Art Pnctl loner Reg(4110) ❑ Mechanical DSPS NoUfieatlon(4115) ❑ Body Art Facility-Single Use (4120) 0 Body Art Faclllty-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehlcleRegl6lra8on# License# Capacity Vehicle Al ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units 50410 WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ A9/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (R cruMs) ❑ DumpcterS>20 cu yd(a or unis) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(45DO) ❑ Primary Care Q Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility O 2- 10 ❑ 11 -60 ❑ > 60 generators pt/BLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITYANO/OR PROGRAM CONTACT PERSON Devin Lambert Day Ph 303-222-6037 Night Ph PROGRAM ELEMENT I L, L FEEaL ❑ Surcharge FEE ❑ Other FEE INSPECTOR J .�' v+ 4'v`" PERMIT VALID a 27 togVal C1Food Handler ❑ C # AMO � AI �J � 0212 �'7 I INvO10E'x/. 2�SI�(a3 Cash ''�V��V�IREVI�EWED BY ACCOUNTING OFFICE Date an-ngs�a MASTERFILE RE ORO'!F VTION PINY, Received Time Aug. 27, 20 12: 15PM No. 6919