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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR INTENT <br /> MASTERFIL CORD INFORMATION FORM <br /> ew EH Program at Existing Facilit ❑New EH Program and New Facilit <br /> Facility ID 0 D 1()5:3 L, Program Record ID c� s�—a- <br /> Facility Address -7 11 E 01 , salve <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No [I <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> E] Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy . ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ State Facility Surchary <br /> HAZARDOUS WASTE PRO( VALLEY HARLEY DAVIDSON <br /> ❑ Hazardous Waste Ge r--- ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handler )liance Recyclers(2217) <br /> Tiered PermittingFacili 711 E. Miner Avenue•Stockton,CA 95202 <br /> Website:www.stocktonhd.com Iditionally Exempt(CE) <br /> ❑ ABOVEGROUND STORA RICH KENDALL nit-By-Rule Household Hazardous Waste <br /> UNDERGROUND STORA Service Manager <br /> HOUSING PROGRAM(2400) 209/941-0420 • FAX 209/463-2100 <br /> 11 Hotel/Motel-------Number of Un nn Number of Units <br /> Employee Housing(2700) Use Employ SALES..................SERVICE..................FASHIONS <br /> SITE MITIGATION(2900) .. ___(3060) <br /> ❑ Environmental Assessment SEP Cleanup Site ❑ U1C Site <br /> ❑ Abandoned HW Site VALLEY HARLEY DAVIDSON ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROC <br /> Number of Pools/Spas at Facility_ (Spa El Natural Bathing Area <br /> 711 E. Miner Avenue•Stockton,CA 95202 g <br /> VECTOR CONTROL PROGRAM i E-Mail:valleyhd711 @earthlink.com <br /> ❑ Poultry Farm -Maximum n Website:www.valleyhd.com ❑ Kennel <br /> TATTOO, BODY PIERCING PEF TERRY DAVIS <br /> ❑ Tattooing(412 1) 1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(420 209/941-0420 • FAX 209/463-2100 <br /> ❑ PumperVehicle--Registration# SA—___..................SERVICE..................FASHIONS Vehicle# <br /> ❑ Pumper Yard ----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility 11 Compost Facility 11Process/Recycle Facility El CIA Landfill Site <br /> ❑ efuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <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 /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 4-7 C• O FEE ❑ Surcharge FEE 11Other FEE <br /> INSPECTOR# PERMIT VALID I (p t-f totp��n ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date `Z b <br /> 48=02-034 Masterfile Record Pink <br /> 11/18/03 <br />