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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT p �pq MASTERFILE RECORD INFORMATION FORM Y ❑ New EH Program at Existing Facility L�New EH Program and New Facility ��CF `'y� Facilit ID �j ^ % Pro ram Record ID ii'� g �% Mqy , �� Facility Address 1126 N Main St., Manteca CA 95336 S F coq 2?OZJ Please check thea ro date descri tion ands eci size number of units and pertinent information.HFq<T�/R N /N OO FOOD PROGRAM (16 0) p p p �—� ) NpFPMRNr �NT)r ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ��❑ ❑ 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 ❑ 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) ❑ ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and 8 forms ❑ Other CUPA Program PBR (2231) ❑PBR HHW (2236) HOUSING PROGRAM (2400) ❑ HotellMotel------Number of Units ❑Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Emolovee Housino/Labor Cama Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑UST -CAP Site ❑Local HW Cleanup Site ❑NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑pop-NPLISEP Cleanup Site ❑ RWOCB 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 iATT00. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) Ag/Cannery Waste Site ❑Sludge/Ash 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) LIOUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station ❑ Waste Tire Facility ❑Compost Facility ❑ Refuse Vehicles la orunasl Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Process/Recycle Facility ❑CIA Landfill Site ❑ Dumpsters > 20 cu yd Ix 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 96-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FAOILITY AND/OR PROGRAM CONTACT PERSON Sylver DeHart Day Ph 209-482-0135 Night Ph PROGRAM ELEMENT ��t � FEE � ❑Surcharge FE ❑Other FEE INSPECTOR# V PERMIT VALID S t0 G .3D .,�/ �-- ❑Food Handler �-p� ❑ Check # I �� AMOUNT PAID �, Date S H INVOICE # u0 J O ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date S 3 48-02-034 /r ` MASTERFILE RE RDI FORMATION PINK 1/23/13 ��- / '� IZi z'%Ze.(t/