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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ®New EH Program and New Facilit Facility ID LADD2,7 SD Program Record ID S Facility Address 730 S. California Street, Stockton,CA 95203 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: 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 r) 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 (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) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B formas ❑ Other COPA 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 ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 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# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) PAY ElLandfill ElTransfer Station ❑ Ag/Cannery Waste Site ❑ SI T C3 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 1:1 CIA La �D ❑ Refuse Vehicles(#or Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Far yr7ch Cleanup Site MEDICAL WASTE PROGRAM (4500) S 12023 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 1:1 Large Generator El Small Generr" �#8d Ha ❑ Transfer Station ❑ Veterinary Clinic ❑HD uler PE46-02-003 Blue ApplicationForm Common Storage Facility ❑ O ❑ 11 NCTyl� PUBLIC WATER SYSTEMPROGRAM (4600) Use PWS gi�Yators EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON A Wg o Day Ph Z,5 9)6 1/ 59 Night Ph PROGRAM ELEMENT 1635 FEE �? ❑9818 Surchar;if25 FEE El Other FEE INSPECTOR# PERMIT VALID 2-1(2,5 t0 2 ❑ Food Handler ❑., Check# AMOU T PAID . —' Date INVOICE# 3R224D Lli G , 'A REVIEWED BY ACCOUNTING OFFICE Date : 2 3 48-k-034 MASTERFILE RECORD INFORMATION PINK 1/23/13