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0 Surchar e F PROGRAM ELEMENT k'4)t `-(4-5 FEE 41) a <br />to <br />Date <br />INSPECTOR # V\CAre`SERMIT VALID 23 <br />Check # AMOUNT PAID <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />El Other FEE <br />0 Food Handler <br />INVOICE # <br />Date / <br />az5)4i4 A5S-37 )06 <br />MASTERFILE RECORD INFORMATION PINK 48-02-034 <br />1/23/13 <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />LI Dumpsters > 9n -- CU yd (# of Units) <br />0 Sludge/Ash Site <br />ID CIA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID F4c02-711q4 <br />El New EH Program at Existing Facility <br />PAY r <br />E1VED <br />JAN 10 2023 <br />SAN <br />JOA QU/N COUNTY ENVIRON <br />MENTA L HEALTH DEPARTMENT <br />ONew EH Program and New Facility <br />Program Record ID - <br />0 w/Meat Market only <br />No <br />Goods Only <br />Facility Facility Address 1720 S. Fresno Ave., Stockton, CA 95206 <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 <br />Commissary 0 Dry storage only 0 with Food Preparation <br />121 Retail Market----Square footage 2,730 sq. ft. <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0CF0 0A0B <br />Food Handlers Course required: YES 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments 21 Prepackaged <br />Color <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility LI 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) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />gi 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 0 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 />[251 Environmental Assessment 0 UST-CAP Site El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site LI 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 0 Pool 0 Spa 1:1 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br /> CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />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 # <br />Pumper Yard <br /> <br />0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />El Refuse Vehicles (it of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 ii - 60 0 > 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 Ross Hillesheim Day Ph (831) 392-6424 Night Ph <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />License # Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units