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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existina Facilitv ❑New EH Proaram and New Facilitv Facility Address 112 E. Yosemite Ave Manteca, CA 95336 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) RECF QED OCT 11 ?021 S ENV AQUTA/ HEgLTH DEpq RTMFNT Y Q IN Restaurant: Seating Capacity 824 Square Footage 20.224 Food Handlers Course required: YES IM No ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ 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 118 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 Cama 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ 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 VehicleRegistration # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles (# of Units) MEDICAL WASTE PROGRAM (4500) Capacity Vehicle # ❑ Chemical Toilets --Number of Units _ ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Dumpsters > 20 cu yd I# of Units) ❑ Farm/Ranch Cleanup Site ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 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 Paramjit Dhanda Day Ph 530-751-6096 Night Ph 530-751-6096 PROGRAM ELEMENToo 1(-4� FEE El surchargeEE 11 Other FEE INSPECTOR# 979,KPERMITVALID 101J1W t0 3I ❑ Food Handler ❑ Check# I 1.5.tf--- AMOUNT PAID .00 DateINVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date /2 Z 48-02-034(16W* � / ,/, MASTERFILE RECORD FORMATION PINK 1123/13 k�l/' �rlry /3-36K-