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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Record ID Facility Address 3422vv. Hammer Lane Unit F, Stockton, Ca 9521 h (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) RF�FMVNT FQ ogR4?9 11 n ❑ Retail Market ----Square footage ❑ w/Meat Market only El Multiple Departments El Prepackaged Goods Only ❑ Produce Restaurant: Seating Capacity Square Footage Food Handlers Course required: yes ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units _ n ❑ Retail Market ----Square footage ❑ w/Meat Market only El Multiple Departments El Prepackaged Goods Only ❑ Produce Mobile Food Vehicle --Make Vehicle Type Color Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color ❑ Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ IJSpecial Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP 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, 2234,2235P 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA 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 Hpusino/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 1`1 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Landfill ❑Transfer Station ® 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 Vehicle Registration # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Uni[s ❑ Landfill ❑Transfer Station ElAg/Cannery Waste Site ❑Sludge/Ash Site 11 Waste Tire Facility ❑ comp ost Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (#ol Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 1:111 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON Meta Chhom Day Pn (209)447-3858 Nignt Pn (209)447-3858 PROGRAM ELEMENT 4110 FEE $152 ❑ Surchar a F ❑ Other FEE INSPECTOR If 9836 PERMIT VALID z 2 IO ❑ Food Handler ❑ Check # I �-- AMOUNT PAID Y.5 • OD Date /Z- INVOICE # ❑ CaSh REVIEWED BY ACCOUNTING OFFICE / Date/% 2h,/ MASTERFILE flECORD9NFORMATION PINK