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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ffNew EH Program at Existin Facility ❑New EH�P}r-ogram and Netiv Facility <br /> Facility ID () Pro ram Record ID �`2 S_�?-7 -7 <br /> Facility Address 3 / 4_� • M(' e-2 Av E STb cLro h <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❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ 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 It 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(2000) <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 ❑Recycle f 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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units ❑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 SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site3310 E.Mine`Ave. ❑Nater Quality Remediation Site <br /> Pacific Stockton,CA 95205 <br /> RECREATIONAL HEALTH PRONorthwest Oil <br /> Number of Pools/Spas at Facility_ Mailing Address: (Spa ❑Natural Bathing Area <br /> - P.O.Box 6930 " <br /> VECTOR CONTROL PROGRAM Stockton,CA 95206 <br /> ❑Poultry Farm Maximum DAN G I S H ❑Kennel <br /> TATTOO,BODY PIERCING,PE <br /> MAINTENANCE SUPERVISOR <br /> ❑ Tattooing(412 1) (Bus:(209)463-4762 3 Permanent Cosmetics 4122) <br /> LIQUID WASTE PROGRAM(421 Fax:(209)463-2566 <br /> ❑ Pumper Vehicle—Registration I Cell:(209)649-8761 Vehicle# <br /> [I Pumper Yard email:dan.gish@pac�cnorthwestoil.com Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> Waste Tire Facility 11Compost Facility 11Process/Recycle Facility 11CIA•LandfilI Site <br /> Refuse Vehicles Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ I1-60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PfVSEHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON //// Day Ph Night Ph <br /> PROGRAM ELEMENT 7/ 7� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ((o PERMIT VALID to ❑ Food Handler <br /> ❑ Check# MIOUNT PAID r1 Date INVOICE# <br /> El cash REVIEWED BY P1405 1 D O ACCOUNTING OFFICE Date <br />