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Check # AMOUNT PAID Date <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 0New EH Program and New Facility <br />Facility ID Al5Voil--16 Program Record ID 7ivt7 .1 <br />Facility Address 582 E Harding Way, Stockton, CA 95204 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No CI <br />CI Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage CI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />1 0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />, 0 Special Event---Dates of operation from to 0 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 />El CalARP Program CI Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />0 Hazardous Waste Generator (2200) >-Tons Generated Per Year Less than 5 tons <br />Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <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 CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El 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 CI Spa CI 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 />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 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 />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility <br /> 0 Process/Recycle Facility CI CIA Landfill Site <br />Refuse Vehicles (t of units) <br /> El Dumpsters >20 cu yd or Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care CI Skilled Nursing CI Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 CI ii -60 0 > 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 <br /> Day Ph Night Ph <br />PROGRAM ELEMENT 2220 FEE 0 Surcharge FEE <br /> <br />0 Other FEE <br /> <br />N. Loehrer INSPECTOR # PERMIT VALID to 0 Food Handler <br /> I VOICE # 3 .(13 <br />kV Date V 457 / 2,0 <br />MASTERFILE RECORD INFORMATION PINK <br />Completed on 9/7/2023 by Nick L. <br />48-02-034 <br />1 /7111'1