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Cash ACCOUNTING OFFICE REVIEWED BY <br />MASTERFILE R COR INFORMATION PINK 48-02-034 <br />1123/13 <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date 7 1.3 <br />0 Surcha <br />to 1 <br />Date <br />PROGRAM ELEMENT 3c, - FEE <br />' <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID 0 <br />0 Ag/Cannery Waste Site <br />I•1 Dr <br />0 Dumpsters >HPKIllriiIIPARI 20 cu yd (# of Units) MGW13nuP Site <br />sW4§64960 5-y <br />aterst <br />r 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 F/607-776,2— Program Record ID W-05-2-{135G./ <br />Facility Address 17401 S Manthey Road Lathrop, CA 95330 <br />(Please utieck tlie appropriate description and speuify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License 14 Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />License # <br />Color <br />Registration # 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 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 />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 <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds <br />TATTOO. BODY PIPRCIHrz, PPPRA A.NPNT r'nMPTIr' 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 VehicleRegistration # <br />Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <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 />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />0 Natural Bathing Area <br />0 Kennel <br /> License # <br />0 Package Treatment Plant 0 Chemical Toilets ----Number ojuLts <br />Capacity <br />Body Art Facility-Single Use (4120) <br />Body Art-Temp EIDAVAMtMility (4131) <br />RE WED <br />12 2023 <br />0 Limited Hauler <br />11 - 60 0 > 60 generators