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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />❑ New EH Program at <br />EH Program and New <br />Record ID <br />Facility Address 721 Carolyn Weston Blvd, Stockton CA 95206 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />10 Restaurant: Seating Capacity5O <br />Square Footage 2211 sq it <br />Food Handlers Course required: YES ® No ❑ <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit— Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />[]CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tans Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <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 ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacilitySingle Use 49 0 <br />ElBody Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobi31) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehi= <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SAN JOPOWN 10tNTI <br />SOLID WASTE PROGRAM (4400) exviaomrer r.' <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludgehbltgite h <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (# 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 ❑ 2 -10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Jason Voyer Day Ph (415) 254-3249 Night Ph (415) 254-3249 <br />PROGRAM ELEMENT (QZ FEE _ ❑ Surchar EE 11 Other FEE <br />INSPECTOR # L �nYW PERMIT VALID " I" -1 2 22 10 " Z ❑Food Handier <br />❑Check# V 6 Is AMOUNT PAID ��i�—� — Date—<4 INVOICE# bD <br />❑ Cash REviEWWED BY ACCOUNTING OFFICE W Dateff//li <br />1/23/13 34 1 � Q 31 � q �- 3 I / �� MASTERFILE RECORD INFORMATION PINK <br />