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New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID Program Record ID ppasii-701 7 <br />PROGRAM ELEMENT lb 17 FEE <br />INSPECTOR P.M ‘ " PERMIT VALID <br />( C <br />uu C # (41014 CIMO AMOUN AID <br />op(i V i5y} REVIEWED BY , <br />48- -034 <br />CI Other FEE <br />25 CI Food Handler <br />INVOICE # <br />Date <br />MASTERFILE RECO" INFORMATION PINK <br />El Surcha ge EE <br />to <br />Date <br />ACCOUNTING OFFICES <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 2910 West Eight Mile, Stockton, CA 95209 <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 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation 0Vending Machines Number of Units <br />12 Retail Market----Square footage 3900 sq ft El w/Meat Market only 12 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <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 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy i2 Milk Dispenser-Number of Containers in Multi-Head Unit 6 <br />CUPA <br />12 Hazardous Materials Business Plan (1900) Number of chemicals: 2 <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) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) N/A <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 />0 Environmental Assessment 12 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) N/A <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) N/A <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) N/A <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) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) N/A <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) N/A <br />Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility <br />Refuse Vehicles (it of Units) El Dumpsters > 7n __ CU yd (# of Units) <br />CI Skilled Nursing 0 Large Generator <br />0 Common Storage Facility CI 2-10 0 11 - 60 0 9‘411149Derators 202+ <br />00N PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form I1 <br />412QU/ <br />FALT 'To* -tool,. <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM HoEp EATAL. <br />CONTACT PERSON Charanjiv Dhaliwal Day Ph 925-446-6806 Night Ph 925-446-0102 T/WEA, <br />MEDICAL WASTE PROGRAM (4500) N/A <br />Primary Care 0 Acute Care <br />Transfer Station CI Veterinary Clinic <br />CI Sludge/Ash SitepAit._ <br />CIA Landfill SijsZirMEArs. <br />Farm/Ranch CIMeeillivi <br />0 Small Generator 0 Li imted <br />Zo <br />1/23/13