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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facili <br />Facilitv ID CA 0 0 1 q-7-7 S <br />Facility Address `JaLZ l L tI,ca. <br />(Please check the appropriate description and specify <br />FOOD PROGRAM (1600) <br />ew EH Program and New Facili <br />m Record ID dD S:56670 <br />q5 a <br />number of units and pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep'Unit <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Make <br />License # <br />to <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Vehicle Type Color <br />Sticker # <br />_ ❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year <br />❑ CRT Offsite Handlers (2218) -------------❑ Silver Only (2222) <br />Tiered Permitting Facilitv------------------- El Conditionally Authorized (CA) <br />❑ ABOVEGROUND <br />UNDERGROUND <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number c <br />Employee Housing (2700) Use <br />SITE MITIGATION (2900) <br />❑ Environmental Assessmi <br />❑ Abandoned HW Site <br />RECREATIONAL HEALTH PRO, <br />Number of Pools/Spas at Fac <br />as so V <br />LOGISTICS <br />Chuck Wilkins <br />Safety Manager <br />E chuck.wilkins@comtrak.com <br />4221 E Mariposa Road <br />Stockton, CA 95215 <br />P 209.943.6971 <br />C 209.323.9806 <br />F 209.465.4948 <br />COMTRAK.COM <br />❑ Recycle/Exempt System (2299) <br />❑ Appliance Recyclers (2217) <br />❑ Conditionally Exempt (CE) <br />Irmit-By-Rule Household Hazardous Waste <br />rms <br />ution ----Number of Units <br />Doo) <br />L/SEP Cleanup Site ❑ UIC Site <br />❑ Water Quality Remediation Site <br />I/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM�'I �rprv. pm rr <br />❑ Poultry Farm -------Maximum number of birds — ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />El Tattooing (4121) El Body Piercing (4120) El Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----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 (# or Units) ❑ Dumpsters > 20 cu yd (# 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 FEE_ <br />INSPECTOR#PERMITVALID <br />❑ Check # AMOUNT PAID _ <br />❑ Cash REVIEWED BY <br />❑ Surcharge FEE <br />- to - <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />