Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />El New EH Program at Existing Facility New EH Program and New Facility <br /> <br />, --r, Facility ID t_ (DI 4 <br /> <br /> <br />Program Record ID r C gq 2, I 6171 <br /> <br />Facility Address 1233 E Charter Way, Stockton, CA 95205 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No 0 <br />CI Commissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />N Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments CI 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 0 Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to CI CFO 0 A CI B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program El Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) CI 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 />CI Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />CI Environmental Assessment 0 UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # Capacity Vehicle # <br />CI Pumper Yard El Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator CI Limited Hauler <br />Transfer Station CI Veterinary Clinic CI Common Storage Facility 0 2 - 10 0 11 - 60 CI > 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 Hank Brown <br />PROGRAM ELEMENT I (2 1 7 FEE ti 30 1 0 Surchar. FEE <br />INSPECTOR # PI , kvii'Ll PERMIT VALID 3729/ 9-1 to 4 30/ -7 0 Food Handler <br />1:1 Check # AMOUNT PAID Date .21 2 INVOICE # T <br />Cash REVIEWED BY ACCOUNTING OFFICE Date V lc123 <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />Day Ph 279-200-2023 Night Ph <br />CI Other FEE <br />C A./.0