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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />New EH Program at Existing Facility <br />Facility ID <br />Facility Address Address <br /> <br />Square Footage <br />0 with Food Preparation <br />0 with Meat Market only <br /> Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />8238 Segarini Ct. Stockton CA 95209 <br />PA ymE,A <br />CE/ 41; <br />MNew EH Program and New Facility APR n n <br />"‘7 <br />Program Record ID PAD5-664S S.44 <br />J <br />2020 <br />0,4 <br />Food Handlers Course required: YES 0 No <br />OVending Machines Number of Units <br />0 Multiple Departments0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Sticker # <br />HE-6Nviii8P'N cou ALN 00,41ENTA tiry <br />ARTmewr <br />0 Ice Plant <br />Color <br />0 Surc rge F E 0 Other FEE <br />INSPECTOR <br />#. <br /> PERMIT VALID 2.0 to 3f) 0 Food Handler <br />Check # 1 /.5 ,4---- AMOUNT PAID "3 bOO Date INVOICE # 3 3- <br />Cash REVIEWED BY ACCOUNTING OFFICE Date 4 <br />PROGRAM ELEMENT q FEE <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator <br />CRT Offsite Handlers (2218) <br />Tiered Permitting Facility <br />El Produce Stand <br />Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />Tons Generated Per Year <br />Silver Only (2222) <br />Conditionally Authorized (CA) <br />Permit-By-Rule Fixed Unit <br />0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd of units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 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 Jessica Bryant Day Ph 209-507-1024 Night Ph 209-507-1024 <br />48-02-034 <br />11/15/07 4//07389?s-1 MASTERFILE RECORD INFORMATION PINK