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0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />Tons Generated Per Year <br />Silver Only (2222) <br />0 Conditionally Authorized (CA) <br />Permit-By-Rule Fixed Unit <br />Recycle/Exempt System (2299) <br />0 Appliance Recyclers (2217) <br />Conditionally Exempt (CE) <br />Permit-By-Rule Household Hazardous Waste <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility El New EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address 575 Industrial Park Drive, Manteca, CA 95337 Truck 519037 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br /> <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No El <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 with Meat Market only 0 Multiple Departments:1 Prepackaged Goods Only <br />El Mobile Food Vehicle --Make 2014 GMC Vehicle Type TR0:1 Color Inca Gold <br />Registration # 1GD675CB9E1135099 License # 42670N1 Sticker # <br />Mobile Food Prep Unit Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator <br />CRT Offsite Handlers (2218) <br /> <br />Tiered Permitting Facility <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <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 />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP 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 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (t or units) 0 Dumpsters > 20 cu yd or units) <br />MEDICAL WASTE PROGRAM (4500) <br />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 11 -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 Vijay Singh Day Ph (209) 824-3011 Night Ph (209) 324-5861 <br />PROGRAM ELEMENT FEE 0 Surcharge FEE 0 Other FEE <br />INSPECTOR # PERMIT VALID to 0 Food Handler <br />Check # AMOUNT PAID Date INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE Date <br />Color <br />Sticker # <br />0 Ice Plant <br />0 Produce Stand <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07