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SAN JOAQUIN COUNTY ENN ONMENTAL HEALTH DEPART NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ew EH Program and New Facility <br /> Facilit H) c) O Program Record ID DSZ L 32 <br /> Facility Address 3 C' Ali(0 e r. <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 ❑ <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 /> ❑ 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 ❑ State Facility Surchar <br /> HAZARDOUS WASTE PRO- IM Auto Dismantler <br /> 13 Hazardous Waste G( Recycle/Exempt System(2299) <br /> Specializing in Late Model New&Used Acura,Honda d Tgyota Parts )]lance ReC clers 2217 <br /> 1:1 CRT Offsite Handle y ( ) <br /> Tiered Permitting Facil TOYOTA We Buy Junk Cars ditionally Exempt(CE) <br /> ACURA Shipping&Hours:M-F 9-i M-FDelivery-5 nit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORE M a7-Mz Sat 10-3 <br /> UNDERGROUND STOR, NISSAN st <br /> _ FREMONt m <br /> HOUSING PROGRAM(2400) Tel (209) 943-1366 <br /> ❑ Hotel/Motel-------Number of Ur Fax (209) 323-5641, -_ P MNER <br /> �"(�� * )n-------Number of Units <br /> Employee Housing(2700) Use f jML 3532 E. Miner Ave. <br /> Stockton,CA 95205 Q <br /> SITE MITIGATION(2900) !(3000) <br /> ElEnvironmental Assessment h c r "' /SEP Cleanup Site El UIC Site <br /> ❑ Abandoned HW Site / rps'. Shipping &Delivery - ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGf <br /> Number of Pools/Spas at Facility_ �^••� I/Spa 11 Natural Bathing Area <br /> .�. <br /> VECTOR CONTROL PROGRAM(L .. <br /> - ❑ <br /> ❑ Poultry Farm -------Maximum nu Hours:M-F 8 6 <br /> Saturday 10-3 5 Kennel <br /> DPW <br /> TATTOO, BODY PIERCING, PERI ACURA HONDA TOYOTA <br /> ❑ Tattooin r -— ❑ Permanent Cosmetics(4122) <br /> g(4121) A fl/S't l'prntl2Cr' ------- <br /> LIQUID WASTE PROGRAM(4200) Mateo <br /> El Pumper Vehicle-Registration# Ph#: (209)943-1366 Vehicle#QGunJ,. "_ <br /> ❑ Pumper Yard 3532 E.Miner Ave Stockton.CA.95205 Fax#:(209)943-1365 __Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle 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 /> 11 Primary Care ❑ Acute Care El Skilled Nursing El Large Generator [3 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----112- 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 't-7 y C) FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 0(0 0 PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY , b �� (✓ ACCOUNTING OFFICE �! Date <br /> 48-02-034 Masterfile Record Pink <br /> 10/6/2003 <br />