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PERMIT VALID <br />PROGRAM ELEMENT <br />INSPECTOR # <br />EI Check* AMOUNT PAID <br />ID Cash REVIEWED BY <br />El Surchar <br />tO <br />Date - <br />ACCOUNTINGACCOUNTING OFFICE <br />0 Other FEE <br />CI Food Handler <br />INvoicE # ID 5-7- <br />Date <br />dAti.) /5•766 /b <br />48-02-034 <br />11/15/07 <br />MASTERFILE RECORD INFORMATION PINK <br />/ FEE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ONew EH Program at Existing Facility <br />Facility ID FAO D-2-762 <br />El New EH Program and New Facility <br />Program Record ID -PpiD5-1-gzi-L-t3 <br />Facility Address 1110 N Main St, Manteca, CA 95336 <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 Food Handlers Course required: YES CI No 0 <br />Commissary El Dry storage only 1:1 with Food Preparation OVending Machines Number of Units <br />El Retail Market----Square footage 3010 0 with Meat Market only CI Multiple Departments0 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 0 Ice Plant <br />Special Event Dates of operation from to CI Produce Stand <br />DAIRY PROGRAM (2000) <br />1:1 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA CI State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />0 Hazardous Waste Generator Tons Generated Per Year 0 Recycle/Exempt System (2299) <br />CI CRT Offsite Handlers (2218) 0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) 0 Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 Permit-By-Rule Household Hazardous Waste <br />0 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />Hotel/Motel ------Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site CI NPLJSEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) 0 Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility CI CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters >20 cu yd (tt or Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care 0 Acute Care I=1 Skilled Nursing CI Large Generator 0 Small Generator 0 Limited Hauler <br />ID Transfer Station 0 Veterinary Clinic 0 Common Storage Facility El 2 - 10 0 11 -60 CI > 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 Brian Friedman Day Ph 209-277-8885 Night Ph