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PROGRAM ELEMENT <br />INSPECTOR # CS <br />Check # i <br />Cash REVIEWED BY <br />48-02-034 <br />1/2 3/13 <br />FEE <br />PERMIT PERMIT VALID <br />AMOUNT PAID <br />El Surc <br />to <br />Date <br />El Other FEE <br />COUNTING OFFICE <br />0 Food Handler <br />INvoicE# <br />Date 7 <br />s MASTERFILE RECORb INF RMATION PINK <br />Food Handlers Course required: YES 0 No CI <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br /> :New EH Program and New Facility <br />Facility ID Fite).0.2:774,..2— Program Record ID Te.C)5 4-1-g5S-", <br />Facility Address 17401 S Manthev Road Lathrop, CA 95330 <br />(Please check the appropriate description alit.' spuuify size, nuitibei of units and pertinent Mon-nation.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br /> <br />DVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # <br /> Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration license Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event—Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility El Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <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 0 NPL/SEP Cleanup Site <br /> 0 UIC Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Abandoned 1-IW Site <br /> <br /> 0 non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site El Water ylityRemediation Site <br />A M <br />E <br />NT <br />0 Spa <br /> 0 Out of Service Pool/SpaRECSIVIEEpthing Area Number of Pools/Spas at Facility CI Pool <br />VECTOR CONTROL PROGRAM (4000) <br />JUL EP te2$23 12 Poultry Farm Maximum number of birds <br />TATTnn, FantlY PIERCING, PERMANENT rnQMPTir PROGRAM (4100) <br />SAN AOAQIJIN.CO.UNTY <br />0 Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art FaMtiRO.Vpmmke (4120) <br />CI Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body ArtireigilEIXEARIMIdifacility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Ag/Cannery Waste Site Landfill 0 Transfer Station <br />n El Waste Tiro Facility' Ell Compost Iacility o Dumpsters > 20 cu yd (# of Unrts) Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Byron Chapman Day Ph 209-609-3417 Night Ph same <br />0 Sludge/Ash Site <br />El CI" Landfill Site. <br />1:3 Farm/Ranch Cleanup Site <br />Generator 0 Limited Hauler <br />11 - 60 0 > 60 generators