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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I <br />MASTERFILE RECORD INFORMATIOW FORM <br />❑ New EH Program at Existing Facility ®New EH Progam rand New <br />Facility <br />Facility ID P 600 11,37` Program Record ID 0"�Sa�' <br />Facility Address _ _ 221 c Mrd i oe scr i'tQn <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: <br />Seating Capacity <br />Square Footage <br />Food Handlers Course required:. YEs ❑ No ❑ <br />❑ Commissary <br />❑ Dry storage only <br />❑ with Food Preparation <br />❑Fending Machines Number of Units <br />❑ Retail Market <br />----Square footage <br />❑ with Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make <br />Vehicle Type Color <br />Registration # <br />License # Sticker # - <br />11 Mobile Food Prep Unit—Make <br />Vehicle Type Color <br />Registration # <br />I Sticker # _ <br />❑TemporaryFoodFacility ----=Datesofopel <br />LOPEZ CUSTOM COMPOSITES — <br />❑ Special Event —Dates of operation from <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B n Multi -Head Unit <br />NOE LoPkz <br />CUPA ❑ State Facility Surcharge (2399) <br />OW <br />HAZARDOUS WASTE PROGRAM (2. <br />❑ Hazardous Waste Generator- Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) NLOPEZ@LCCOMP.COM -�cyclers (2217) <br />Tiered Permitting Facility 4452 S H WY 99 FRONTAGE RD 209-614-9303 Exempt (CE) <br />STOCKON, CA le Household Hazardous Waste <br />95215 <br />❑ ABOVEGROUND STORAGE TAN. <br />. UNDERGROUND STORAGE TANF rT rc'n nnnOv A *,t rliru» rr. rrcr a -4 M r - <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel Number of Units <br />Employee Housing (2700) Use Employee Housil <br />SITE MITIGATION (2900) <br />❑ Environmental Assessment ❑ UST-( <br />❑ Abandoned I1W Site ❑ non -N <br />RECREATIONAL HEALTH PROGRAM (36 <br />Number of Pools/Spas at Facility . <br />VECTOR.CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of 1 <br />Rascon Trucking <br />Rudy Rascon <br />Location: 4221 Mariposa Rd. <br />Stockton, Calif. 95215 - <br />Mailing: 4222 Rosenbaum Ave. <br />San Jose, Calif. 95136 <br />Fax# 2o9-644-8232 <br />Fax# 408-972-1207 <br />Cell# 408-705-5208 <br />R.Rascon@comeast.net <br />TATTOO, BODY PIERCING PERMANENT COSMETIC PRWGRAM (4100) <br />umber of Units <br />M <br />Site ❑ UIC Site <br />xality Remediation Site <br />:1 Natural Bathing Area <br />❑ Kennel <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity <br />Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant • ❑ Chemical Toilets <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Jdandfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />®/Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA -Landfill Site <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator D Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --0 2 - I O <br />❑ 11- 60 ---❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIPS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR TIi15 FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph <br />Night Ph <br />PROGRAM ELEMENT d FEE ❑ Surcharge FEE <br />El Other FEE <br />INSPECTOR# (H q PERMIT VALID to <br />❑ Food Handler <br />❑ Check It AMOUNT PAID Date <br />INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />Date <br />- <br />M <br />