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Nov, 6. 2014 3:21AM Joaquin County No, 3970 P. 4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM PAYMENT ❑ New EH Program at Existing Faclll REQ' IVED n 11111111INew EH Pro ram and New Facilit Faclll (D /f Pr4_ram Record ID 3 NOV 13 2014 Facility Address 1 a greens opt St Stockton CA 95205 _ (Please check the appropriate description and specify size, num4er_of units and pertinent information,) SAN JIVIROM COUNTY ENVIROMENTAL FOOD PROGRAM(1600) HEALTH DEPARTMENT Restaurant: Seating Capacity Square Footage Food Handlers course re uiredi YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machlnes Number of Units =Retail Market -Square footage ❑ Mobile Food Vehicle—Make [J1114 820 with Meat Market only Multiple Departments Prepackaged Goods Only Mob Registration# Vehicle Type Color El Mobile #Mobile Food Prep Unit Sticker# Make Vehicle Type Color Registration# - License# ❑ Temporary Food Facility--dates of operation frcm Sticker# 11 Special Event Dates or operation from to ❑ Ice Plant DAIRY PROGRAM(2000) to ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dalry © Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------'ions Generated Per Year ❑ Recycle/Exempt System(2259) ❑ CRT Offsite Handlers(2218) -------------❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ---------- -------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camo Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site 0 Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIG site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quallty Remedlatlon Slte 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,E10DY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard EJPackage Treatment.Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) © Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(*ur unite) ❑ Dumpsters a 20 cu yd(#of units) ❑ Farmiaanch Cleanup$ite MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 0 Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHO 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Store Mqr: Tonia Tong Day Ph 209-467-7861 Night Ph 916-601-3448 PROGRAM ELF,ME-N.T FEE ❑ Surcharge FE ❑ Other FEE �I.N{,SP�EUCIR 4 FfTh PERMIT VALID (3 to l ❑ Food Handler heck MOUNT PAI Date INVOICE# -2577, !P(p (u� Cash REVIEWED B �j ACCOUNTING OPFICE Date �( f 4802.034 MASTERFILE RECORD INFORWATION PINK 11/15107