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Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 Cu yd (# of Units) <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />ed Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Common Storage Facility 0 2 - 10 0 ii - 60 0 > 60 generators <br />0 Surchar <br />to / <br />Date <br />ACCOUNTING OFFICE <br />PROGRAM ELEMENT 3612 FEE 70.5 <br />INSPECTOR # 9828 PERMIT VALID 7 <br />Check # CPA+ AMOUNT PAID <br />Cash REVIEWED BY <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br /> EINew EH Program and New Facility <br />PAYMENT <br />RECEIVED <br />Facility ID t2-77t.3 Program Record ID PROSLI-5Z5AS JUL 05 2023 <br />SAN <br />(Please check the appropriate description and specify size, number of units and pertinent information.) ENVIRONMENTAL <br /> COUNTY <br />FOOD PROGRAM (1600) HEALTH DE PARTMENT 0ENT <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES <br />0 N <br /> <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 with Meat Market only 0 Multiple Departments0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit Make Vehicle Type <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br /> 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year <br /> O Recycle/Exempt System (2299) <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) <br /> 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) <br /> O Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit <br /> O Permit-By-Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />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 1 0 Pool El Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Facility Address 3651 Arch Road, Stockton, CA 95215 <br />Color <br />0 Ice Plant <br />0 Produce Stand <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skill <br />Transfer Station 0 Veterinary Clinic <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 Kim Bogdan Day Ph 562-676-7760 Night Ph <br />48-02-034 <br />11/15/07 \t/ 14,03oso___ MASTERFILE RECORD INFORMATION PINK