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SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR ENT <br /> MASTERFILE RECORD INFORMATION FORINT U u 'V��F�VjF,D <br /> ElNeNewEH Program at Existing Facility New EH Program and New Facility <br /> Facility ID 'Dol lokna Program Record ID q 3 NOV 2 9 2005 <br /> Facility Address 1401 Pine Sf. ENVIRONMENT HEALTH <br /> (Please Check the appropriate description and specify size, number of units and pertinent information.) PERMIT/SERVICES <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: N*Es ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <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 ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility-Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility------------------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use GSTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Emplo)ee housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment ElUST-CAPSite ❑ Local HIV Cleanup Site ElNPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW 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 /> ❑ Tattooir.;(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(-1122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> NVaste"fire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--NmllhC1 Of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ElPrimary Care El Acute Care ❑ Skilled Nursing El Large Generator [:],Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PiVS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> rPR0GRA, NiEi,i,"mE'NT ���O FEE ❑ Surcharge FEE ❑ Other FEE <br /> crol;# 00(c,QPERMI:fVAt.IDto ❑ Food Handler <br /> eck# ANIOUNTPAID Date INVOICE#sh REVIEWED B1' jt It �1 5 ACCOUNTING OFFICE Date �Z � a� <br /> Nlastertile Record Pink <br /> 48-02-034 <br /> 10/6:2003 <br />