Laserfiche WebLink
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 SHAHBAJ SING AULAKH Day Ph 669-261-0213 Night Ph <br /> <br />LEI ck # 13-531(0$2te AMOUNT PAID <br />Cash REVIEWED BY <br />Date <br />ACCOUNTING OFFICE 4AAYfrd <br />Other FEE 0 Surcharge FEE <br />to t Food Handler <br />INVOICE # <br />Date <br />PROGRAM ELEMENT I U FEE <br />INSPECT # G F PERMIT VALID <br />SAN 'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility 0 New EH Program and New Facility <br />Facility ID 2_3(D3F <br /> <br />Program Record ID KiD5-41-g/ <br />Facility Address 1164 BESSEMER AVE, UNIT-2 MANTECA <br />(Please check the appropriate description and specify size, number of units and prtinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 1:1 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation I:Vending Machines Number of Units <br />Retail Market----Square footage 300 0 w/Meat Market only 0 Multiple Departments 'Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CU PA <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) 0 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 8 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 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP 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 />Poultry Farm Maximum number of birds <br /> 0 Kennel <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) 0 Body Art-Temp Event Mobile Facility (4131) <br />Registration # License # <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 0CF0 0A0B <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles of of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled <br />Transfer Station 0 Veterinary Clinic <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />El Dumpsters > 20 cu yd of of Untts) <br />Nursing 0 Large Generator 0 <br />0 Common Storage Facility 0 2 - 10 <br /> <br />License # Capacity Vehicle # <br /> <br />0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA LandfilpfAbil <br />lr 0 Farm/Rank... Ev <br />Extt..evien <br />Small Generator 0 LirAtind,tiauler <br />0 >WfiAiai-a032,4, <br />SAN, JoAr) mi -WA/ CouNT 1/41.- - iRoNmEN _ y <br />669-261-0.94PEr-AfirmEisir rAL, <br />11 - 60 <br />48-02-034 <br />1/23/13 CttgrAtrcie <br />MASTERFILE <br />u-7-6 <br />RECORD IN ORMATION PINK <br />a"