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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM A4 YM R(New EH Program at Existing Facility ❑New EH Program and New Facility PtE cj � 1/ 0 Facility ID e)024o '4 Program Record ID E�5"J NOV / 0 Facility Address 3422 W Hammer Lane Ste. F, Stockton CA 95219 SA/V,10S 2020 A FOIOD PROGRAM (1600) appropriate description and specify size, number of units and pertinent informationJi, "ZZ. N' �j CO �NTY ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ N9 Ir ❑ 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 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 (200D) ❑ 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) ---------- ❑ Aboveground Storage Tank Facility (AST) ( BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) UNDERGROUND >-Tons Generated Per Year ❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PER HHW (2236) 2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A 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) BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) 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 ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site (� Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body ProcesslRecycle Facility 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 Units ❑ PROGRAM ELEMENT 6III0 FEE � ❑ Surcharge E 11 Other FEE 7F INSPECTOR# 983 PERMIT VALID 1' t0 �3 11 Food Landfill 11 Trans Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility 11 Comp Facility ❑ ProcesslRecycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd wof 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 ❑ 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 Fong Vang Day Ph 916-715-8401 Night Ph Har ❑ Check# 1.50- AMOUNTPAIL •�� Date INVOICE#�• ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 3 1 /2 311 034 n MASTERFILE RE OI 1/23/13