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Lt JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT pqY MASTERFILE RECORD INFORMATION FORM RFcFMFNr ❑ New EH Pro ram at Existin Facili ew EH Program and New Facili yF Facilit ID 2 72� Program Record ID �7 �� SqN AUG O Facility Address 1810 Pacific Ave Stockton, CA yFFNvz4QUl ?0?� (Please check the appropriate description and specify size, number of units and pertinent information.) A(Ty0 pgFQNC TY FOOD PROGRAM(1600) Tjy EI Restaurant: Seating Capacity 44 Square Footage 2800c0 ft Food Handlers Course required: YES❑ No T ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration At License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ 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 UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution —Number of Units Employee Housing(2700) Use Employee HousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site 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.BODY 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 ❑ Package 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles)#of Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACTPERSON Mary Her L DayPh206-318-8705 Night Ph PROGRAM ELEMENT 169X� FEE Y� 3 ss ❑ SurcIn e F E ❑ Other FEE INSPECTOR# AI-5��y PERMITVALID I 2 t0 a ,31 �'�/- ❑ Food Handler p- ❑ Check#AMOUNT PAID .SSSS. 00 Date H INVOICE# 3S ^ / O ❑ Cash REVIEWED 13Y ACCOUNTING OFFICE Date I/��-1 48-02-034MASTERFILE RECORD INFORMATION PINK �i 115/07