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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT fi►_6I"NA 14:7x0101 11 ❑ New EH Proaram at Record ID PAYME RECEIVED MAR 01 2021 Facility Address 1126 N Main St., Manteca CA 95336 SAN JOAQUIN COUNTY Please check theappropriate descri tion and specify size number of units and pertinent information. I HEATHDEPARTMENT ENVIRONMENTAL (description P fY_, ) i. HEALTH DEPARTMENT FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit-- Make Vehicle Type _ Registration # License #_ ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from to ❑ Multiple Departments ❑ Prepackaged Goods Only to _ Color Sticker # Color Sticker # ❑ Ice Plant ❑ Produce Stand ❑CFO ❑A❑8 DAIRY PROGRAM (2000) ❑ Landfill ❑ Trans fer Station ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 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 B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel ------ Number of Units ❑ Jail or Exempt Institution ---- Number of Units Employee Housing (2700) Use Employee Housinu/Labor Camp 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 ❑ non-NPLISEP 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 _ ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) My, ❑ Spa ❑ Out of Service PoollSpa ❑Natural Bathing Area LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # License ❑ Pumper Yard ❑ Landfill ❑ Trans fer Station 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) # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) PROGRAM ELEMENT A1110 FEE � ❑ Surchar a FE El Other FEE _ INSPECTOR# � PERMITVALID t0 6p3O El Food ❑ Landfill ❑ Trans fer Station ❑ Ag/Ca nnery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles Vof units) ❑ Dumpsters > 20 cu yd (# 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 46.02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Sylver DeHart Day Ph 209-482-0135 Night Ph Handler ❑ Check# _IV1/!� AMOUNTPAID W. 610) Date 4J Z INVOICE#� �3�� ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date % /47z 48-02-034 MASTERFILE R COR INF woo I