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PROGRAM ELEM NT \ \4.,.)kj.)(-<"-) FEE <br />INSPECTOR # PERMIT VALID <br />Di Check # AMOUNT PAID <br />kto C h Visri REVIEWED BY <br />Surch <br />FIE1 to z <br /> Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />CI Food Handle <br />INVOICE # 3 <br />Date <br />48-OZ-0Y4 <br />1/23/13 <br />ASTERFILE RECORD INFORMATION PINK <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existing Facility 121New EH Program and New Facility <br />Facility ID 041irl, 2A9!7 Program Record ID 7 4•06.1(8rM3 <br />Facility Address 1849 Orvis Dr., Stockton, CA 95209 <br />(Please check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage <br />El Commissary 0 Dry storage only CI with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />CI Temporary Food Facility --Dates of operation from <br />1=I Special Event---Dates of operation from <br />number of units and pertinent information.) <br />Food Handlers Course required: YES El No CI <br />OVending Machines Number of Units <br />CI Multiple Departments 0 Prepackaged Goods Only <br /> Color <br />Sticker # <br /> Color <br />Sticker # <br />to 0 Ice Plant CI Produce Stand <br />to 12CF0 OADB <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CU PA <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CI CalARP Program 0 Program 1 Facility CI Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > - Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) CI 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 />CI Hotel/Motel Number of Units CI 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 CI UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site <br />Abandoned HW Site El non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility 0 CIA Landfill Site <br />CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of units) 0 Farm/RaAppimup Site <br />MEDICAL WASTE PROGRAM (4500) R EN <br />El Primary Care CI Acute Care CI Skilled Nursing 0 Large Generator CI Small Generator CI Limit iiitt-r% <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility CI 2 - 10 0 11 - 60 OFIV generators‘i <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CI Natural Bathing Area <br />0 Kennel <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM 'IA/JO <br />CONTACT PERSON David Rainwater Day Ph 209-639-5913 Night Ph 2 <br />27 2022