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DocuSign Envelope ID:A343E9B7-F170-42F1-A502-ECA948201444 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Ny l MASTERFILE RECORD INFORMATION FORM Rc cMF r El New EH Program at Existing Facility 13New EH Program and New Facility A' `C`/V 6 FacilityID Q�� q� Program Record ID 'VOP 3 Sq fFacilityAddress� 1105 W-Yosemite Ave,Manteca CA 95337 IV 0,70 010 `Please check the appropriate description and specify size number of units and pertinent information. HFq�ry pO p UoutyTy ( PP P P P N ) FOOD_PR_OG_R_AM (1600); 4RrMF CO Restaurant Seating Capacity 0 Square Footage 862 sgft Food Handlers Course required: YES❑ NO br ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑,Retail Market----Square footage n/a ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only (E1 Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)----—---->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233, 2234, 2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles t#of units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ,CONTACT,CT,PERSON Rob//ert Richardson(local Manager) 1 rDay Ph 509-392-1250 CNigh h 509-392-1250 PROGRAM ELEMENT 6 FE ❑ Surcharge EE ❑ Other FEE INSPECTOR# s7XlT PERMIT VALID 14 OZd t0 11 6 A� ❑ Food Handler 11Check# l/150-- AMOUNT PAID Date l Gtr INVOICE# 3 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date A 48-02-034 A ^ 'y'.-/I(/�f MASTERFILE RECOR INFORMATION PINK 1/23/13 `--1//l/(J, 4//, (( O ;-8