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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility [NNew EH Program and New Facility <br />Facility ID 022E2— 2 Program Record ID go s l b <br />Facility Address 5308 PACIFIC AVE STE 1000, STOCKTON, CA 95207 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />IN Retail Market --Square footage >2000 ❑ w/Meat Market only ❑ Multiple Departments IN Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility —Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200)-------> -Tons Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) _egENT <br />LlHotel/Motel ------Number of Units 11 Jail or Exempt Institution ----Number of U��FF't�,•�z yMENT <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) N0� 3 0 2022 <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Ris"Wrute <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />HEPLTH HEMRTMENI <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ 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 (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ FarmlRanch 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 Juan Martinez Day Ph 209.684.7077 Night Ph 209.684.7077 <br />PROGRAM ELEMENT 161$ FEE ElSurcharge F <br />❑ Other FEE <br />INSPECTOR# 9818 PERMITVALID II 241 <br />2A t0D 2D <br />❑ Food Handler <br />11 Check # a IS AMOUNTPAID 74 <br />� Date <br />IINVOICE # <br />❑ Cash REVIEWED <br />ACCOUNTING OFFICE <br />Date 11 <br />L <br />`BY / <br />48-02-034 ^ �7 <br />1/232-3 [ Il.' ' S�lp <br />111 yl /LL <br />MASTERFILE ECOR INFORMATION PINK <br />J/� ( <br />, <br />