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IF 'BAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility 1ZNew EH Pro ram and New Facility Facility ID r aOa7�}23 Program Record ID �ZXo Facility Address 180 Northwoods Ave Manteca, Ca 95336 (Please check the appropriate description and specify size, number of units and pertinent information.) FO�PROGR—AM(1600) Resl}f taurant: Seating Capacity 2 U Square Footage Food Handlers Course required: YES Ell-'Nio ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ 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) ❑ CIE (2233, 2234, 2235, 2237) ❑ PER(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 85 ❑ Jail or Exempt Institution----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 ❑ 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 EventrglQliile Facility(4131) LIQUID WASTE PROGRAM(4200) IWEIY ❑ Pumper Vehicle Registration# License# Capacity ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) NOV 1 [[ ❑ Landfill ElTransfer Station ❑ Ag/Cannery Waste Site u e/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ 1�7{yyT1. ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of Units) Lh�UrFpIBE� (�.}y7lENT Site MEDICAL WASTE PROGRAM (4500) "^ENT ❑ 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 Sam Patel Day Ph - - Night Ph 408-219-9434 PROGRAM EL MEpNcT� FEE , ❑ Surch ge F E El FEE INSPECTOR# 00 PERMITVALID L Tic, t0 '/ [I Food Handler heck# l� 0 AMOUNT PAID 3sb Date 2'L-INVOICE# 7/a3g� ash REVIEWED BY �01( '' ACCOUNTING OFFICE Date /4ZL 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13