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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P4Y►�ENT MASTERFILE RECORD INFORMATION FORM RECEIVED ❑New EH Program at ExistlnFaclll 13 New EH Pr ram and New Faclll Faclll ID O0 a� Program Record ID EB 16 Z�21 FacilityAddfess 4770 West Lane,Stockton,CA95210 1 AN JOAQUIN COUNTYENVIRONME DEPARTMENT (Please check the appropriate description and specify size,number of units and pertinent Infortnatlon. EALTH NTAL FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ ❑Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle–Make Vehicle Type Color Registration At License# Sticker At ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration At License# Sticker# ❑Temporary Food Facility–Dates of operation from to ❑ Ice Plant ❑Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility----❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution--Number of Units Employee Housing(2700)Use Employee HouslnNlabor Cams)Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility I IN Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ ProcessfRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#or units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Mike Quismondo Day Ph (209)915-0275 Night Ph (209)9154275 FN ELEMENT 361 1 FEE 783 ❑ Surcharg FE ❑ Other FEE # %380 PERMIT VALIDto �— ❑ Food Handler /.5� AMOUNT PAID O b Date r'o Z INVOICE#REVIEWED BY /��,A/CcouNTING OFFICE Date ,3 98-02-039 yam. / /��J��n MASTERFILE RECORD INFORMATION PINK 11/15/07 '`I i-V l 7