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EHD Program Facility Records by Street Name
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PALERMO
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1600 - Food Program
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PR0547084
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Entry Properties
Last modified
10/28/2021 11:14:39 AM
Creation date
10/28/2021 11:13:43 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
BILLING
RECORD_ID
PR0547084
PE
1608
FACILITY_ID
FA0026699
FACILITY_NAME
KAI'S KITCHEN 808
STREET_NUMBER
1263
Direction
S
STREET_NAME
PALERMO
STREET_TYPE
LN
City
MOUNTAIN HOUSE
Zip
95391
CURRENT_STATUS
01
SITE_LOCATION
1263 S PALERMO LN
P_LOCATION
03
QC Status
Approved
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SJGOV\jcastaneda
Tags
EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ElNew EH Proaram and New Facilitv <br />G Facility ID Proqram Record ID <br />Facility Address 1263 South Palermo Lane, Mountain House, CA 95391 <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 />Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending MachiAes Number of Units <br />❑ Retail Market --Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />® CFO EI A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ 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 ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <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 />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator C}Y,.yq(�gd.HHauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility <br />El - 10 ❑ <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form E�VEp <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ,,II,,II <br />CONTACT PERSON Kainn1o��a Garcia Day Ph 808-258-9426 Night Ph 808-2"2 <br />PROGRAM ELEMENT 1 q� FEE _ ❑ Surcharge FFEE ❑ Oth/e.rr� O n��''"///'''ppA••• a����..��Oyy��� <br />INS ECTOR# L % f PERMIT VALID -Z9 -2� t0 .2 U ZZ ❑ FOOq-Igb ,QL°MUNTY <br />Check # �ua AMOUNT PAID Date ` ZI INVOICE # VuLt EEfyT <br />ElCash REVIEWED BY ACCOUNTING OFFICE pAA7/7</ Date <br />1/23/13 <br />
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