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,SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proaram at Existing Facility ONew EH Proaram and New Facility <br />Facilitv ID f'ADOZ6JSO(, Program Record ID <br />Facility Address 110 W Oak Street, Lodi, CA 95240 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />F OD PROGRAM (1600) <br />Restaurant: Seating Capacity 120 Square Footage 5800 <br />Food Handlers Course required: YES ® No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle–Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event --Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit _ <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200)---> -Tons Generated Per Year <br />❑ Tiered Permitting Facility —> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR'(2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housina/Labor Cama Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -----Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # <br />❑ Pumper Yard <br />❑ Natural Bathing Area <br />❑ Kennel <br />❑ Body Art Facility��30) <br />13 Body Art -Temp Ee fg1iltty (4131) <br />License# Capacity <br />�ghtc�la_ <br />❑ Package Treatment Plant ❑ Chemical Toilets --Number o Its <br />SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUIITY <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site�ANT <br />13 Waste Tire Facility 13 Compost Facility ❑ Process/Recycle Facility 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 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON Y1/6ti4K-p Day PhNight Ph 9FiA4,-� <br />PROGRAM ELEMENT�IPERMITFVALID <br />EE 2 ❑ Surch e F ❑ Other FEE <br />FCC <br />EC70R# Z!/ to D to 2i7— ❑ Food Handier // <br />heck# _ AMOOU/N�T/PAID %'� Y Date L INVOICE# 4 <br />ash REVIEWED BY I iV " `i ACCOUNTING OFFICE / Date '7/1-7/2/ <br />1/23/13 <br />