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JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />INFORMATION FORM <br />❑ New EH Program at Existing Facility 1ZNew EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address 180 Northwoods Ave Manteca, Ca 95336 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FO�PROGR—AM (1600) <br />N(Restaurant: Seating Capacity 2 U Square Footage Food Handlers Course required: YES ED -'No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type Color _ <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />Produce Stand <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 />❑ CalARP 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 UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel ------Number of Units 85 ❑ 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 ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP 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 />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <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 EventrglQllile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) IWEIY <br />❑ Pumper Vehicle Registration # License # Capacity <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) t'e <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site u e/Ash Site <br />❑ Waste Tire Facility 1:1 Compost Facility ❑ Process/Recycle Facility ❑ 1�7tyNTy <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# or Units) Lh�UrFpIBE� (�.}y7lENT Site <br />MEDICAL WASTE PROGRAM (4500) "^ENT <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 -60 ❑ > 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 Sam Patel <br />Day Ph Zu'-Z"-UZaU Night Ph 4Ub-219-9434 <br />PROGRAM EL mr=NcT� FEE <br />, ❑ Surch <br />ge F E <br />ElOther FEE <br />INSPECTOR# 00 PERMITVALID <br />114112-o 1-L t0 <br />'/ <br />11 Food Handler <br />heck# l� 0 AMOUNT PAID <br />3sb Date <br />%��INVOICE# %/a3g7 <br />ash REVIEWED BY `01(&(rP <br />ACCOUNTING OFFICE <br />Date /4yy <br />48-02-034 <br />MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />