BILLING - Laserfiche WebLink

Home Browse Search

10/20/2005 16:49 4640138 ENVIRONMENTAL HEALTW PAGE 03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTEUME RECORD INFORMATION FORM ❑NeW EH P at Exj!ggg Facility IgNcw EH prograrn and New Facility Facie .IA O D 161-L1 Program Record ID 1)'Itg Facility Address 248 West Fremont Street Stockton CA 95203 (please Check the approptisto description and specify size camber 01-0-FAIM and pertinent Information.) FOOD PROGRAM(1600) A Restaurant: Sea ing Capacity Square Footage Food Handlers Course,reaui Yt:s❑ No❑ ❑ Commissary ❑Dry amiage only ❑with Food Preparation ❑Vending Machines-Number of Units ❑Rebul Market--Squarofootage ❑with Mest Market only ❑Muhi ie Departments 13Prepackaged Goods Only ®Mobile Food Vehicle----Make Vehicle Type �hkt� Color Registration# License# Sticker# 0 ❑ Mobile Food"Unit-Make VdriekType Color RgiogDgripn# License# Sticker# L3 Temporary Food Facility—Dates E3 produce Stand Plant of operation frau to 13 Ice [3cial SpeEvent -Dates of operation from to nd DAIRY PROGRAM(2000) ❑Grade A Dairy ❑ Grade X Dalry i3 Milk Disp user—Nunllxr of Containers iu Muhi-Head Unt— MpA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) 13Haxordous Waste Generator -Tons Generated Per Yearp Recycle/Exempt System(2299) 13 CRT Offsite Handlcm(2218) 13 Silver Only(2222) 13 Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑Conditionally Exempt(CE) ❑permit-By Rule Fixed Unit ❑Pertmt-By-Ruie Household Hazardous Waw ❑ABOVEGROUND STORAGE TANK FACH TfY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UAJA and oras HOUSING PROGRAM(2400) E3 Hok Matd----Number of Unita ❑Ina K Exempt Institution- -Ima'ber of UAtts Employee Housing(2700)Use Aoagiaa/Laher Carp An&—clop Form SIT8 Mfl7GATION(2900) Uhv��i:ROUND INJECTION CONTROL ❑UIC Site ❑Eovtroameptal Assessrueut ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NP[JSEP Cleanup Slee ❑Abandoned HW Site ❑ sou-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Qttanty Remxdlation Site RECRFAXIANAULFAL PROD (3600) (]Natural Bathing Area Nouber ofPools/Spes at Facility 1-1 Pool Q spa (3 out of Service Poo1/Spa g VF_CTOR CoWkQL PROGRAIN(4000) ❑Kennel ❑poultry Farm—M®r®um number of birds 00 00DY 1 PE AHE COS Eno OG (4100) [3 permanent Cosmetics(4122) [3 Tattooing(4121) t]Body p1ercinB 120) h rump WASTE PROGRAM-(4200) Liceese# Capacity Vehicle# ❑Pumper Vehtio ick—Registran# ❑Package Treatment Plant 13 Chemical Toilets---Number of Unix ❑Pamper Yard SOL D�OGRAM(4400) [3 All!Cannery Waste Site ❑Shidge/Ash Site ❑Landfill ❑Transfer station ❑CIA Landfill Site ❑Waste lire Facility ❑compost Futility ❑Procexs/R-Nuck Faerof 17 Refaso Veb►des--Nunba of Units ❑IharrpAers>20 m yd—Numbtr of Uaitt ❑ FarmlRaovr Ctanap Sik MED�PROGRA�N (4500) a Generator ❑Small Generator ❑Umited Hauler ❑ Primary Care U Acute Care ❑Sloped Nursing Q Lurg d 2.10—❑ 11-60—la>60 generators 13Transfer Station [3Veterinary Cloth: t3Common Storage Facility— PUBLIC WATER SYSTEM PROGRAM(4600)Use fi D I6-02-#03 lue A ' ' a Forfil mtaWENCY ItOTIFICATiON FOR Tilts FACILITY AND/OR PROGRAM 209 518-8154 CONTACI'PERSON Patrick BI i o Day ph (209) 518-8154 Night Ph ( ) �O -Fns- . L-25�. _❑SarehsrgeFu ❑other FU -- - --PRO4'RAM ELEMEKT. � . - IMPaCfOR# p �bp l q4 qp pt Wrr VALID t o to L S o b ❑Food Handler (p Check 11 AMOUNT PAID J IGS Date—, L11-1101c, INVOICE# (q/�_ �. 13 cub REVIEVEDaY ACCOUNrNC;OFFICES Date l� oS •a......Fu.arrmil Pink