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New EH Program at Exin__2jsti g pci <br />Facility ID 01171) ado y Program Record IDJ91:1 514:1- 0b9 <br />DalNew EH Pro ram and New Facility <br />S-C1 p4r- -‘c MASTERFILE RECORD INFORMATION PINK <br />env( 11/15/07 <br />4k vlas-r till <br />48-02-034 er-b <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 2400 Constellation Way, Lathrop, CA 95330 <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 required: YES 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 with Meat Market only 0 Multiple Departments0 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 />CI Temporary Food Facility --Dates of operation from to 0 Ice Plant <br />CI Special Event Dates of operation from to 0 Produce Stand <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy ' 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA 0 State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator Tons Generated Per Year 0 Recycle/Exempt System (2299) <br />CRT Offsite Handlers (2218) 0 Silver Only (2222) 0 Appliance Recyclers (2217) <br />Tiered Permitting Facility 0 Conditionally Authorized (CA) CI Conditionally Exempt (CE) <br />0 Permit-By-Rule Fixed Unit 0 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 0 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 0 UST-CAP Site 0 Local HW Cleanup Site CI NPLJSEP Cleanup Site CI UIC Site <br />CI Abandoned HW Site 0 non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 1 Pool lEl 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Tattooing (4121) CI Body Piercing (4120) 0 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill I El Transfer Station 0 AgICannery Waste Site 0 Sludge/Ash Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator 0 Small Generator 0 Limited Hauler <br />El Transfer Station CI Veterinary Clinic 0 Common Storage Facility 0 2-10 0 11 -60 0 >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 Layne Jensen, Project Manager Day Ph 925-542-0646 Night Ph 925-542-0646 <br />PROGRAM ELEMENT e.3 /44, I ( FEE El <br />INSPECTOR PERMIT VALID 2,021t0 I 1, <br />Surchar FEE Other FEE <br />I: Food Handler <br />El Check # AMOUNT PAID Hy • 527 Date le9( t4 INVOICE # Cg 0 27 <br />CI Cash REVIEWED BY ACCOUNTING OFFICE Date A