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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ®New EH Program and New Facility Facility ID Program Record ID Facility Address 1355 W. Atherton Dr. Manteca, CA 95337 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ® Restaurant: Seating Capacity. 0 Square Footage 657 Food Handlers Course required: YES® No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ®Vending Machines Number of Units 2 ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ 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: ❑ CaIARP 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) ❑ PER(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 EventPM tFffility(4131) LIQUID WASTE PROGRAM(4200) RECEIVED ❑ Pumper VehicleRegistration# License# Capacity Vehic a# 1:1 Pumper Yard 13 Package Treatment Plant ❑ Chemical Toilets—Number of li �'f SOLID WASTE PROGRAM(4400) eJapawx cop n ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slu,q�e 'r ElWaste Tire Facility ElCompost Facility 11Process/Recycle Facility 101 CIA�Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd I#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 PERSON Melissa Eliazar Day Ph 510.414.3971 Night Ph 510.414.3971 PROGRAM ELEMENT I FEE ❑ Surcha ge F E ❑ Other FEE INSP`E 1CT'.OR# � PERMIT VALID ,iy., ) f0 ' ❑ Food Handier ❑ c 1t1M SLt AMOUNT PAID Lt.�7�✓ J Date 2 I 1 VOICE# l ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 2, 48-02-034 /� 1 q (,� /_ ASTERFILE RECORD INFORMATION PINK 1123/13 /� 131 (,