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48-02-034 <br />1/23/13 /4, S3L (fsi,S- <br />FEE PROGRAM ELEMENT • ,s- <br />ACCOUNTING OFFICE <br />INSPECTOR # <br />Check # <br />Cash <br />PERMIT VALID <br />AMOUNT PAID <br />REVIEWED BY <br />MASTERFILE RECORD IN ORMATION PINK <br />Other FEE <br />Food Handler <br />INVOICE// 3 g <br />Date 7 23 <br />• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br />Facility ID Oa 2_774,2— Program Record ID PI21)54g 5 6.0 <br />Facility Address 17401 S Manthey Road Lathrop, CA 95330 <br />(PICLIbt l;l1CL:k the applupt iate description arid specify size, [Milli:lel of units and perlir rent infofinetion.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />0 Commissary 0 Dry storage only 0 with Food Preparation <br /> <br />OVending 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 # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />0 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 />0 Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 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 />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 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />O Pouftry Farm Maximum number of birds 0 Kennel <br />Food Handlers Course required: YES 0 No 0 <br />TATTOO, BODY PERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # <br />Pumper Yard <br /> <br />0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (tt of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br /> 0 <br />Transfer Station 0 Veterinary Clinic 0 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 />Capacity <br />Ag/Cannery Waste Site <br />n Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of units) <br />-44itcit 2 2023 <br />!J./Ma-144%10EN? <br />ClA Landfill Site <br />0 Farm/Ranch Cleanup Site <br />ENVIRONMENTAL <br />0 Limited Hauler <br />> 60 generators <br />Body Art Facility-Siarirr <br />Body Art-Temp Eve rat 31 ) <br />0 Chemical Toilets ----Number SIANtlibAQUIN COUN <br />Small Generator <br />11 - 60 <br />CONTACT PERSON Byron Chapman Day Ph 209-609-3417 Night Ph same <br />