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0 Surcharige F <br />1(17/02, to / / <br /> Date <br />ACCOUNTING OFFICE <br />0 Other FEE <br />12 Food Handler <br />INVOICE It <br />Date <br />'212 2 <br />PROGRAM ELEMENT 28145 3 I FEE <br />N. Loehrer INSPECTOR ft PERMIT VALID <br />Check # <br />ID Cash REVIEWED BY <br />AMOUNT PAID <br />CI Out of Service Pool/Spa El Natural Bathing Area <br />CI Kennel <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility Of New EH Program and New Facility <br />Facility ID <br />Facility Address 1691 S Lower Sacramento Rcri 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 0 <br />CI Commissary 0 Dry storage only CI with Food Preparation CI Vending Machines Number of Units <br />Retail Market----Square footage I=1 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy CI Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />CI Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program 0 Program 1 Facility CI Program 2 Facility 0 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) 0 PBR (2231) 0 PBR HHW (2236) <br />Di Aboveground Storage Tank Facility (AST) (2800) Number of ASTs less than 10,000 <br />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />0 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 0 NPL/SEP Cleanup Site DM Site <br />CI Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool CI Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 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 It <br />CI Pumper Yard CI Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (#01 units) El Dumpsters > 20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing <br />Transfer Station 0 Veterinary Clinic 1:1 Common Storage Facility 0 2 - 10 <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 />Day Ph Night Ph <br />48-02-034 MASTERFILE R ORD INFORMATION PINK <br />.1 /91/11 <br /> <br />Completed on 9/7/2023 by Nick L. <br />License # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to CI Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to CI CFO 0 A 0 B <br /> Capacity Vehicle It <br />0 Chemical Toilets ----Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />0 Large Generator CI Small Generator CI Limited Hauler <br />0 11 - 60 0 > 60 generators <br />CONTACT PERSON