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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> X New EH Program att Existing Facility gNew EH Program and New Facility Facility ID Program <br /> Record ID <br /> Facility Address 1721 Chaparral Way Stockton CA 95209 <br /> (Please check the appropriate description and specify size, number of units and pertinent <br /> information.) FOOD PROGRAM(1600) <br /> ❑ Restaurant:Seating Capacity Square Footage Food Handlers Course rgguired:YES o No❑ o Commissary <br /> ❑ Dry storage only ❑ with Food Preparation ❑Vending MachinesNumber of Units ❑ Retail Market----Square footage <br /> ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -- <br /> Make Vehicle Type Color <br /> Registration# License# Sticker# ❑ Mobile Food Prep <br /> Unit--Make Vehicle Type Color Registration# <br /> License# Sticker# <br /> ❑Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ <br /> Special Event---Dates of operation from to X CFO X 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 /> ❑ CalARP Program o Program 1 Facility o Program 2 Facility o Program 3 Facility ❑ Hazardous Waste <br /> Generator(2200)---------->-Tons Generated Per Year <br /> ❑Tiered Permitting Facility -------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER(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) <br /> ❑ Hotel/Motel------Number of Units ❑Jail or Exempt Institution ----Number of Units Employee <br /> Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment o UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑Abandoned <br /> HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa o Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> o Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING, <br /> PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art <br /> Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicleRegistration# 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 ❑ Waste Tire Facility ❑ Compost Facility ❑ <br /> Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles p of units) ❑ Dumpsters > 20 cu yd (#of Units) ❑ <br /> Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care o Acute Care o Skilled Nursing o Large Generator❑Small Generator❑ Limited Hauler❑Transfer Station ❑ <br /> Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use <br /> PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Stephanie Perry Day Ph 925-435-9867 Night Ph 925-435-9867 <br /> PROGRAM ELEMENTj b69 FEE o Surcharg FEE ❑ Other FEE <br /> 4 <br /> INSPECTOR# D O PER,fN144AALIID y121 2.3 ❑Food Handler ❑Check <br /> # 54--- AMOUNT PAID /' X"—- 6ate 72-2— INVOICE# 377035 El Gas REVIEWED <br /> BY ACCOUNTING OFFICE Date <br />