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ACCOUNTING OFFICE <br />to 3 3 -2-5- 0 Food Handler <br />Date • Pi 2. INvoicE # 3q' <br />Date 3 <br />1/23/13 <br />48-02-034 <br />177057i-1-3f <br />MASTERFILE RECORD INFORMATION PINK <br />CONTACT PERSON Laura Padilla Day Ph 209-278-7572 Night Ph 209-278-7572 <br />Surchar. FE. 0 Other FEE <br />Cash REVIEWED BY <br /> PERMIT VALID44 3h2 /2•41- <br />AMOUNT PAID 7119 I?-Oo <br />FEE 186 PROGRAM ELEMENT 1608 <br />INSPECTOR # 8788 <br />Check # <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID <br />Facility Address 26735 Airport Ct, Manteca CA 95337 <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 <br />Commissary CI Dry storage only CI with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br /> <br />El Mobile Food Vehicle —Make Vehicle Type <br /> <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br /> <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <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) CI 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 GI 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 NPLJSEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El 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 CI Pool CI Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI 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 />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />CI Pumper Yard CI Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles f# of Units) 0 Dumpsters > 20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care El Acute Care CI Skilled Nursing 0 Large Generator Cl Small Generator D Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic 0 Common Storage Facility CI 2 - 10 <br /> <br />0 11 - 60 El >60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />ONew EH Program and New Facility <br />Program Record ID --PkDSLI-V1/1,:n <br />84 N JOA <br />Nii/R8L8N COUN 1.141-Th' Ep4 <br />Food Handlers Course required: YES El No i5Air <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />FE8 2 6 2024 <br />, P" 474-7- <br /> Capacity Vehicle # <br />0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site