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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ® New EH Proaram at Existina Facilitv ❑ Record ID Facility Address 1448 Orqullo lane, Manteca CA 95336 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: MESS ❑ 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 L1Ag/Cannery Waste Site Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Refuse Vehicles (# of 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: ❑ 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, 22353 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA 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/LaborCamp 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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool ❑❑❑ VECTOR CONTROL PROGRAM (4000) L1Poultry Farm -------Maximum number of birds Spa Out of Service Pool/Spa Natural Bathing Area (4100) El Kennel ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) D 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) 11 Pumper Vehicle Registration # License # Capacity Vehicle # 11 Pumper Yard El Package PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/ORPROGRAM Treatment Plant ❑Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill El Transfer Station L1Ag/Cannery Waste Site ElSludge/Ash Site 11 Waste Tire Facility 11 Compost Facility ElProcess/Recycle Facility 11 CIA Landfill Site ❑ Refuse Vehicles (# of units) 13Dumpsters > 20 cu yd (# of units) 11Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El Primary Care L1 Acute Care 11 Skilled Nursing El Large Generator L1 Small Generator 11 Limited Hauler 11 Transfer Station 11 Veterinary Clinic El Common Storage Facility ❑ 2 - 10 1:111 - 60 11> 60 generators CONTACT PERSON RVlvpr npHart Day Ph 9094820135 Night Ph PROGRAM ELEMENT 161110 FEE •.i 1:1Surcharg FEE 11 Other FEE INSPECTOR# PERMIT VALID f0 013 6 �— El Food Handler 11Check# SA- AMOUNT PAID .�v Date -5 INVOICE# El Cash REVIEWED BY ACCOUNTING OFFICE Date 3 48-02-034 ^ , / MASTERFILE R C D INFORMATION PINK 1123/13 OV� 1.2.1/