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New EH Program at Existing Facility <br />Facility ID 'EA 002-170) <br />ONew EH Program and New Facility <br />Program Record ID rg.05 -61 g 4 8 q <br />o Surcha ge FEE <br />to 30 23 El Food Handler <br />INVOICE # 3 F 03 <br />Date 6 .7 <br />0 Other FEE <br />Date <br />ACCOUNTING OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 1351 w yosemite Manteca Ca 95337 <br /> <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />12 Restaurant: Seating Capacity 95 Square Footage 3,300 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 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 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 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 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 El Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 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 />0 Kennel Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br /> <br /> License # <br />0 Package Treatment Plant Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Ag/Cannery Waste Site Landfill 0 Transfer Station <br />Process/Recycle Facility Waste Tire Facility 0 Compost Facility <br />El Dumpsters > 90 CU yd (# of Units) Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator El Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 ii - 60 0 > 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 />thuan do Day Ph 253-314-6468 Night Ph 253-314-6468 CONTACT PERSON <br />Food Handlers Course required: YES El No 0 <br /> Capacity Vehicle # <br />El Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />PROGRAM ELEMENT r 71 6 ? c FEE <br />INSPECTOR # gq-g, PERMIT VALID <br />Check* CC AMOUNT PAID <br />Cash REVIEWED BY 6--F-- <br />48-02-034 MASTERFILE RECORD iNFORMATION PINK <br />1/23/13