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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility dNew EH Program and New Facility <br />Facility ID 4ott517 2:1S-5q— Program Record ID f 4,0 6111 <br />Facility Address 1691 S Lower Sacramento Rd, Lodi, CA 95242 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No LI <br />Commissary CI Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />CI Retail Market----Square footage El w/Meat Market only CI Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to El Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to CI CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <br />12' Hazardous Materials Business Plan (1900) Number of chemicals: 6 <br />CalARP Program CI Program 1 Facility 0 Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units CI 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 CI UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site CI dic Site <br />CI Abandoned HW Site CI non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site Cl Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa CI Out of Service Pool/Spa D Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm-------Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station 0 Ag/Cannery Waste Site CI Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility Cl Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# or units) El Dumpsters 20 cu yd (# of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care 0 Skilled Nursing Cl Large Generator 0 Small Generator 0 Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 2 - 10 CI ii -60 CI > 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 1921 FEE El Surcharge FEE CI Other FEE <br /> <br />}{ N. Loehrer <br /> <br />INSPECTOR rt PERMIT VALID to CI Food Handler <br />Check # AMOUNT PAID Date INVOICE # <br />CI Cash REVIEWED BY ACCOUNTING OFFICE 044 Date q ( <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1 /91/1'1 Completed on 9/7/2023 by Nick L.