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SAN 70AQtTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORRIATION FORM <br /> IdNew EH Program at Existing Facility ❑New EH Program and Nei),facility <br /> Faci t It 'ID 1 , L .7'"Z Pro ram Record ID Sib Sa <br /> Facility A ddres's F-)10 r1me r A-t,^_ <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs El NO <br /> ❑ Commissary ❑ Dry storage only [I with Food Preparation ❑Vendiag Nfachiaes-Number of Units <br /> ElRetail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackagcd Goods Only <br /> ElMobile Food vchicle--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 El ice Plant <br /> El 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 Mufti-Head Unit <br /> CUPA ❑ State Facility S <br /> HAZARDOUS WASTI CaliforniaAUtotech <br /> ❑hazardous�Y 11 Recycle I Exempt S}'stern(2299) <br /> • ' • repair •' Appliance IZecyclers(2217) <br /> ❑CRT Offsite I - <br /> Tiered PerrnittinKabir Conditionally Exempt(CE) <br /> Manager <br /> Permit-lay-Rule household Hazardous)Vaste <br /> 510 E. Miner Ave <br /> ❑ ABOVEGROUND Stockton <br /> UNDERGROUND rnrs <br /> HOUSING PROGRAM(24PH:209-939-0988 <br /> ❑ Hotelllllotel--Numb, • �astitution Number of Units <br /> • •• <br /> Employee housing(2700)Us <br /> .>h <br /> SITE MITIGATION(2900) _ �. TROL(3000) <br /> ® Eavironateatal Assessn � IdPLJSEP Cleanup Site ❑USC Site <br /> ElAbandoned HAY Site d CALIFORNIA AUTOTECH ;ite ❑Water Quality Remediation Site <br /> RECREATIONAL HEALT Complete Automotive Service&Repair <br /> Number of Pools/Spas at Fa cc Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PR( • <br /> ❑ Poultry Farm Ma ❑Kennel <br /> TATTOO,13ODY PIERCI <br /> ❑ <br /> ❑ Tattooing(4121) El Cosmetics(4122) <br /> LIQUID WASTE PROGR Phone (209)939-0988 <br /> ❑ Pumper Vehicle-Regi! 510 E. Miner Ave. Fax: (209)939-0976 city Vehicle# <br /> Stockton, CA 95202 www.californiaautotech.com oilets Number of Units <br /> ❑ Pumper Yard <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill El Transfer Station 11 Ag I Cannery Waste Site 11 SludgelAsh Site <br /> 0 Waste Tire Facility ❑ Compost Facility ❑ Process(Recycie Facility ❑ CIA.Landfill Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ PrimaryCare ❑Acute Care ❑ SlilledTlursing ❑ Large Generator 0 Small Generator ❑Limited hauler <br /> ❑ Trausfer Station ❑Veterinary Clinic ❑ Common Storage Facility--❑ 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PFf'S13XD f6-02-003 $IueApelica(iorz Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOtR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PRoCIL4MELEn1ENT 41 741Z,J I'EE ❑ Surcharge FEE ❑ Other FEE <br /> INsrF_CTOR4 cRe_ -r_) PERMIT VALID to ❑ Food handler__ <br /> Cd Date- <br /> F-1 <br /> ate <br /> Date 0 (( <br /> ❑ !'ash I:Ii`'IS�'lF.J B1' ACCOUNTING OFFICE &—�--�---_—.__-- <br />