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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 19 New EH Program at Existing Facility ❑New EH Proqram and New Facility Facility Address 1616 E Hammer Ln, Stockton, CA 95210 (Please check the appropriate description and specify size, number of units and pertinent information.) F D PROGRAM (1600) �J ResCtT taurant: Seating Capacity 0 Square Footage N/A Food Handlers Course required: YES*'i No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle–Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit– Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event --Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year ❑ Tiered Permitting Facility-----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee Housinp/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles )#of Units) Capacity Vehicle # ❑ Chemical Toilets —Number of Units PAY ❑ Ag/Cannery Waste Site ❑ Slucl* Slte ❑ Process/Recycle Facility ❑ c1= 111-PiQ021 1:1❑ Dumpsters > 20 cu yd I# of units) Fa rich Clear up Site MEDICAL WASTE PROGRAM (4500) s"ENV NONOE4TAL NIMEN, Cl Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator BALWi ed 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 Robert Scott Tyler Day Ph 940 295 7135 Night Ph 940 295 7135 PROGRAM E ME T L ( :5 FEE INSPECTOR# PERMITVAL ❑ Check # V t 5 it_. AMOUNT PAID ❑ Cash REVIEWED BY 1/23/13 c)V- ff �A ❑ St to Date ACCOUNTING OFFICE 13 (0 18 6 L ❑ Other FEE _ ❑ Food Handler INVOICE# e Date / 2,3