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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facili Facility ID Program Record ID Facility AddreSS 450 Commerce Court Manteca, CA 95336 (Please check the appropriate description and specify size, number of units and Pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 0 Retail Market --Square footage 375 ❑ w/Meat Market only ❑ Multiple Departments 0 Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration # License # Sticker# ❑ Mobile Food Prep Unit-- Make Vehicle Type Color 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, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A 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 HousinalLabor Camo 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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds El Kennel TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ 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 FPacilitvMi ) LIQUID WASTE PROGRAM (4200) RECEIVED' ❑ Pumper Vehicle Registration# License# Capacity Vehicle At ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) j0P0orNc005L El Landfill 11 Transfer Station 1:1Ag/Cannery Waste Site ElSludge/Ash Si�vi00NPp r' s r�sl"4 te ❑ Waste Tire Facility 11 Compost Facility ❑Process/Recycle Facility El CIA Landfill Site ❑ Refuse Vehicles (# of 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 112 - 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 Allan Rodriguez Day Ph 209-815-3189 Night Ph 209-815-3189 PROGRAM ELEMENT4 101-V FEE INSPECTOR # % U PERMIT VAL ❑ Check #,C–C, AMOUNTPAID ❑ Cash REVIEWED BY 48-02-034 1/23/1µ IJ3 ^f ' W ❑ Surch 1ge F _ t0 f/O Date z ACCOUNTING OFFICE ❑ Other FEE ❑ Food Har INVOICE# ' Date y 2 ?22i