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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Rece, MASTERFILE RECORD INFORMATION FORM LIVE® ❑ New_EH Program at Existing Facility ❑Nuw LIi Program and New F 0EC 0 _.._,and-New .acilit� 2023 Facility ID Program Record IDL(Z05+gg22— a S N J'ENOAQUIN COUNTY Facility Address MENZ _.8&_S_�iV�I�C.._9.9_StoCkton, CA 9521 5 HEALTHDOEPAR AL (Please check the appropriate description and specify size, number of units and pertinent information.) ARTMENT 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 ❑ 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: ❑ CalARP 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()231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs___ _ ❑ Underground Storage Tank Program (UST)(2300)Use UST A and B forms ❑ Other CUPA 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP 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 (4 100) ❑ 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 _ _ SOLID WASTE PROGRAM(4400) ElLandfill ❑ Transfer Station ElAg/Cannery Waste Site Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(tim u,),i,o ❑ Dumpsters> 20 cu yd(a of Units) _ ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON__JI t Day Ph (209) 481 7445 Night Ph (209) 481 7445 PROGRAM ELEMENT 1 '` FEE 376 ❑ Surcl FE ❑ Other FEE INSPECTOR# " 8 PERMIT VALID //- ^2-y3� (0 1 3� 2 ❑ Food Handler ❑ Check# _ ( AMOUNT PAID cp•w Date Z 7 INVOICE# J I D)-.o ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 I�� I^� MASTERFILE REC RD FORMATION PINK 1/23/13 yl Note: Okay to issue permit (SR0085210)