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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ®New EH Program and New Facility <br /> FacilityID 2�j' Program Record ID 9-'0 �j 5� <br /> Facility AddreSS 21677 N.Devries Rd,Lodi,CA 95242 <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 Food Handlers Course re uire / YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Numb?of Units <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ epackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type /Color <br /> Registration# License# Sficker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser um r of Conta' ers in Multi-Head Unit <br /> CUPA <br /> ® Hazardous Materials Business Plan(1900) Number of chemicals: 3 <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 aci ' y Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Y�r <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2 4, 2235, 2 7) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST)(2800) Number o A <br /> ❑ Underground Storage Tank Program(UST)(2300) Use UST A nd B <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ; ❑ <br /> /L '1 ail or Exempt Institution----Number of Units <br /> Employee Housing (2700) Use Em /o ee Housin abor C /A tf Form <br /> SITE MITIGATION(2900) UND RGROU NJECT N CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site Local1 Cleanup Site ElNPL/SEP Cleanup Site ElUIC Site <br /> 11Abandoned HW Site [I non-NPL/SEP CI anup e ' ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool a ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of bir ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization(4121 ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard Package Treatment Plant ❑ Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Tran, fer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <br /> 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 Day Ph Night Ph <br /> PROGRAM ELEMENT 1958 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# Cesar Ruvalcaba PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 2,LSIZ.20 2lJ <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 Cesar Ruvalcaba 12/16/19 <br />