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PAYMENT RECEIVED <br />DEC 0 7 2023 <br />SAN JOAQUIN COUNTY <br />HEALTH <br />ENVIRONMENTAL DEPARTMENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility H Program and New Facility. <br />Facility ID Program Record ID <br />Facility Address Address 4850 S NM 99 Stockton, CA 95215 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity <br />Commissary 0 Dry storage only <br />Retail Market----Square footage <br />Mobile Food Vehicle --Make <br />Registration # License # <br />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 />Special Event---Dates of operation from to 0CF0 [DAUB <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPPi <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >- Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231 U PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use US T 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site U non-NPL/SEP 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 El Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds D 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 VehicleRegistration # Licent,e 0 Capacity <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (y ii.) <br />MEDICAL WASTE PROGRAM (4500 <br />Acute Care 0 Skilled Nursing 0 <br />Veterinary Clinic D Common Storage Facility <br />INSPECTOR # 828 PERMIT VALID <br />Check # It AMOUNT PAID gib <br />Cash <br />48-02-034 <br />1/23/13 <br /> /71Z22- <br />Note: Okay to issue permit (SR0085210) <br />Square Footage <br />0 with Food Preparation <br />0 w/Meat Market only <br /> Vehicle Type <br />Food Handlers Course required: YES 0 No 0 <br />(=Wending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Vehicle # <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of U. <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (si of umis) <br />—0 Oiudge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />Primary Care <br />Transfer Station <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 Jivtesi Gill Day Ph (209) 481 7445 Night Ph (209) 481 7445 <br />PROGRAM ELEMENT 1614 FEE $376 0 Surcharg FE 0 Other FEE <br />I IJ 2-3 to 1 3 ( 0 Food Handler <br />Date iD INVOICE # <39D zza, <br />REVIEWED BY ACCOUNTING OFFICE Date / <br />MASTERFILE REC RD FORMATION PINK <br />Large Generator <br />0 2- 10 <br />Small Generator 0 Limited Hauler <br />0 11 - 60 0 > 60 generators