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N SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Prooram at Existing Facility Yreew EH Program and New Facility <br />Facility Address�2* 0U4f -3 LODI . Nq Ctr) (U <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 4'/ V " Food Handlers Course required: YES ❑ 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 Tvpe Color <br />Registration # <br />❑ Mobile Food Prep Unit <br />Registration # <br />❑ Temporary Food Facility –Dates of operation from <br />❑ Special Event Dates of operation from <br />License # <br />Make <br />License # <br />to <br />to <br />Sticker # <br />Vehicle Type Color <br />Sticker # <br />❑ Ice Plant <br />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 ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) -- -------- –❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <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 USTA 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 <br />❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Food Handler <br />❑ Poultry Farm ------Maximum number of birds - <br />❑ Kennel <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />INVOICE # y <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />�(I <br />ACCOUNTING OFFICE Tit// /1 /,hW <br />❑ Pumper Vehicle Registration # License # Capacity <br />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 <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) <br />❑ Farm/Ra fAPSInup Site <br />MEDICAL WASTE PROGRAM (4500) 1ftr <br />11 Primary Primary Care Acute Care Skilled Nursing ❑ Large Generator Small Generator LIm1tNe <br />11Transfer Station 13Veterinary Clinic 13Common Storage Facility 132 - 10 11 11-60 genera <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form`�'�u 1j % 20 <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Ry„OAQ(II �� <br />CONTACT PERSON �^1 _ Day PhJ � Night Ph N `�ry/RON NC <br />OUN <br />PROGRAM ELEMENT t I/. FEE, 9 ❑ Surcharge FEE ❑ Other FEE &j1. <br />IINNSPPECTOR# <br />PERMIT VALID7-uZ4 <br />t0 i7p I UZ L <br />❑ Food Handler <br />LN Check # <br />AM�OU�N;T PAID <br />Date �f-� <br />INVOICE # y <br />11 Cash <br />REVIEWED BY lett U YJA <br />�(I <br />ACCOUNTING OFFICE Tit// /1 /,hW <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />