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-SAN JOAQUIN COUiv TY'ENVIRONMENTAL HEALTH DIVISION <br />NIASTERFELE RECORD INFORMATION FORM (EH 00 69) <br />❑ New EH Pro¢ram at Existing Facility 061AVi ew EH Program and New Facility <br />I Facility ID CA000205118 Prnaram Recnrd m 1 <br />Facility Address 400A N Cluff Ave., Lodi, Ca. 95240 <br />(Please Check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course reauired: Yrs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market --Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle—Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Ualt—Make <br />Registration # <br />❑ Temporary Food Facility—Dates of operation <br />❑ Special Event - Dates of operation from— <br />DAIRY PROGRAM (2000) <br />from <br />Vehicle Type Color <br />License # Sticker # <br />to ❑ Ice Plant <br />Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ NMI< Dispenser—Number of Containers in Multi -Head Unit <br />COPA XState Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator --!L�- �Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST RIMMED ^����D <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and 3 forms I1�0''�---''�0!!1'L��(I�Jv" <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution—4(0er o6LJ@@n <br />Employee Housing (2700) Use Employee Housine/Labor Camo Application Form �J� <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30WIVIR ONM ENT HEALTH <br />C1 Environmental Assessment C1UST-CAPSite ❑ Local MY Cleanup Site ❑ NPL/SEP cR"&NT1&ERV1MUIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing .Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Tattooing (4111) ❑ Body Piercing (4120) <br />❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License,! Capacity <br />Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Tollets—Number <br />of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />❑ Farm/Rancb Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ <br />Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 .10 <br />— ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIFS EH0069 Blue Applicadon form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/GR PROGRAM <br />CONTACTPERSON UIQK Uu <br />Ph <br />PROGRAM ELEMENT FEE - ❑ Surcharge FEE <br />INSPECTOR# k%LS PERMIT VALIILT— to <br />11 Check AMot1NT PAID Date <br />❑Cash REVIEWED aY ACCOUNDNG OFFICE <br />Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date <br />EH 0069 PINK FORbt.doc Rev. 07107wv <br />