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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE7ARTII2LNT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existia Facility ew EH Program and New Facility _ <br /> Facilit +ID v D o I L Program Record ID Q-o S3 Y Fll <br /> Facility Address X 33 rk'r8e;� sf Ste" - i iny-) q_�rczo_5 <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 Ilandlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ 1llobile 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_ ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(20W) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Generator.-- Tons Generated Per Year Cl Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B ramrs <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotenlotel Number of UritsNumber of Units <br /> Employee housing(2700)Use F,mplo�e YOUR OUTLET SOURCE FOR TIRES 6 WHEELS <br /> We Carry ALL Major Brands <br /> SITE MITIGATION(2900) )00) <br /> ❑ Environmental Assessment C T Cleanup Site ❑UIC Site <br /> El Abandoned IiY Site TW O UTO Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROG • <br /> Number of Pools/Spas at Facility a ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4 <br /> ❑ Poultry Farm Maximum nut JAY GILL Tel:209/463-4440 ❑Kennel <br /> TATTOO,BODY PIERCING,PER 153B E.Market St. Fax:209/463-6038 <br /> Stockton.CA 95205. email:ealesptwoutlet.com <br /> ❑ Tattooing(412 1) Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> D audfill El Transfer Station 13 Ag I Cannery Waste Site 11Sludge/Ash Site <br /> Vaste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator CJ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---D 2- 10 ❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EfID46-02-003 BlueAnnlica(ion FOMI <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph _ Night Ph <br /> r� i <br /> PROGRAM ELEMENT Z `-y� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ;7 PERMITVALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date_ ,, a INVOICE# <br /> El Cash REVIEWFD BY ACCOUNTING OFFICE -Gallate 3 <br />