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'SAN JOAQUIN COUNTY ETIrVIRONMENTAL HEALTH DIVIS <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 PAYMENT <br /> RECEIVED <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID� <br /> Q '/ /` 'Pro ram`�Record ID / D;; , I`7 <br /> Facility Address 1065 E . Turner Road , Lodi , CA 9521+0 SPUB30AOUIN UNT <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) ENVIRONMENTAL N ,iT <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity t Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Elven,ding 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 Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation `from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) - <br /> ❑ Hazardous Waste Generator-----------------------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 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ 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 ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC 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 ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRADA(4200) <br /> ❑ Pumper Vchicle--Registration# License# Capacity - Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer-Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility .❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> Refuse Vehicles--Number of Units 16 �Dumpsters>20 cu yd----Number of Units 69 ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) (S <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------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Annlicalion Form <br /> EMERGENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE:' ❑ Surcharge FEE` ❑ Other FEE <br /> INSPECTOR#: //_ SJ PERMIT VALID to (r 30/o P- ❑ Food Handler <br /> heck# ,A 0-019 AMOUNT PAID Date !1 L d - INVOICE# <br /> :-1 Cash REVIEWED BY ACCOUNTING OFFICE Date � b <br />