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PROGRAM ELEMENT <br />INSPECTOR # <br />CI Check # <br />CI Cash <br />PERMIT VALID 1//to 50 "2/0 2-1!.:> 0 Food Handler <br /> <br />AMOUNT PAID Date INvoicE # 3 gS ti- <br /> <br />FEE Surchat• e FE 0 Other FEE <br />3 20 2 REVIEWED BY ACCOUNTING OFFICE alfri Date jiD <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existing Facility <br /> <br />'New EH Program and New Facility <br />Facility ID fkfir) 02 -Mc <br /> <br />Program Record ID PA) <br />Facility Address 3210 Pacific Ave Stockton Ca 95204 <br />(Please check the appropriate description <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage <br />1:gi Commissary CI Dry storage only Cl with Food Preparation <br />Cl Retail Market----Square footage El w/Meat Market only <br />0 Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Food Handlers Course required: YES 0 No 0 <br />0Vending Machines Number of Units <br />0 Multiple Departments CI Prepackaged Goods Only <br /> Color <br />Sticker # <br />and specify size, number of units and pertinent information.) <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />CI Temporary Food Facility --Dates of operation from to CI Ice Plant CI Produce Stand <br />CI Special Event---Dates of operation from to <br /> CI CFO DADB <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CU PA <br />0 Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program CI Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />CI Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />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 CI 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 CI Local HW Cleanup Site CI NPL/SEP Cleanup Site CI UIC Site <br />0 Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds <br /> 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />CI Pumper Yard <br /> 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />CI Waste Tire Facility 0 Compost Facility <br />CI Refuse Vehicles (# or Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care 0 Skill <br />Transfer Station 0 Veterinary Clinic <br />CI Chemical Toilets ----Number of Units <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />License # Capacity Vehicle # <br />El Ag/Cannery Waste Site <br />CI Process/Recycle Facility <br />El Dumpsters > 20 cu yd (# of Units) <br />ed Nursing CI Large Generator CI Small Generator 0 Limited Hauler <br />CI Common Storage Facility CI 2 - 10 0 11 -60 CI > 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 Hector Denis Day Ph 209-275-8865 Night Ph <br />48-02-034 <br /> MASTERFILE RECORD INFORMATION PINK <br />1/23/13