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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ® New EH Proaram at Exist Facility Address 29 E MARCH LN - STOCKTON, CA 95207 (Please check the appropriate description and specify side number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Coursereouired: YES ❑ 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 I 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) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use LISTA 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 Housing/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 ❑ 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facllity-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 VehicleRegislration # License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill 11 Trans Station ❑ AglCannery 11 Waste Tire Facility 11 Compost Facility 11 Refuse Vehicles (At of Units) Capacity Vehicle # El Pumper Yard ❑ Chemical Toilets ----Number of Units MEDICAL WASTE PROGRAM (4500) El Primary Care 11 Acute Care ❑Skilled Nursing ®Large Generator 11 Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 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 Barbara Wunder Day Ph 561-912-3030 Night Ph 303-886-6721 PROGRAM ELEMENT FEE ❑Surcharge FEE El Other INSPECTOR# Check # 11 Cash 48-02-034 /23/13 PERMIT VALID _ AMOUNT PAID REVIEWED BY t0 _ Date FEE 11 ❑ Food Handler INVOICE # ACCOUNTING OFFICE Date Waste Site ❑Sludge/Ash Site ❑ ProcesslRecycle Facility ❑CIA Landfill Site ❑ Dumpsters> 20 cu yd (# of Units) El Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El Primary Care 11 Acute Care ❑Skilled Nursing ®Large Generator 11 Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 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 Barbara Wunder Day Ph 561-912-3030 Night Ph 303-886-6721 PROGRAM ELEMENT FEE ❑Surcharge FEE El Other INSPECTOR# Check # 11 Cash 48-02-034 /23/13 PERMIT VALID _ AMOUNT PAID REVIEWED BY t0 _ Date FEE 11 ❑ Food Handler INVOICE # ACCOUNTING OFFICE Date