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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility MNew EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address 2348 Stanfield Dr., Stockton, CA <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units 0 Retail Market—Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only 0 Mobile Food Vehicle —Make Vehicle Type Color Registration # License # Sticker if 0 Mobile Food Prep Unit— Make Vehicle Type Color Registration if License # Sticker # 0 Temporary Food Facility —Dates of operation from to 0 Ice Plant 0 Produce Stand 0 Special Event—Dates of operation from to El CFO M A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: 0 CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility 0 Hazardous Waste Generator (2200)------->-Tons Generated Per Year 0 Tiered Permifting Facility -----> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel —Number of Units 0 Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MMGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site 0 Abandoned NW Site 0 non-NPUSEP 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 0 Spa 1:1 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) gAX MENT Poultry Farm—Maximum number of birds 0 <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) REC E I VE D <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-SingIMt9(41129irm 0 Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp EventiYobile rathI*14131) <br />LIQUID WASTE PROGRAM (4200) SAN JOAQUIN COUNTY <br />Erig CI Pumper VehicleRegistration if License if Capacity migtsmENTAL 0 Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets —Number ofi TH DEPARTMENTtRitis <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site 0 Waste Tire Facility CI Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site 0 Refuse Vehicles (# of Units) 0 Dumpsters >20 cu yd (# of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care CI Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 CI ii - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />E GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Alanah GrlIPA R Y Day Ph 2092426321 Night Ph <br />PROGRAM ELEMENT 1608 FEE 186 0 Surcharge FEE 0 Other FEE <br />PERMIT VALID tO / 0 Food Handler <br />Check # V1-7 AMOUNT PAID 4' 37,G' — Date INVOICE if <br />/9 <br />El Cash REVIEWED BY <br />48-02-034 <br />1/23/13 V MASTERFILE RECORD INFORMATION PINK <br />INSPECTOR # 9838 <br />ACCOUNTING OFFICE Date