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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facility <br />Facility ID N-D-72.2:11-411,0 <br />IgINew EH Program and New Facility <br />Program Record ID pk.,05-iiss--41.6\ <br />Facility Address 351 Danbury PI, Lathrop CA 95330 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 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 # 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 El Produce Stand <br />Special Event---Dates of operation from to 0 CFO 171,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 CI 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 />l Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />CI 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 CI UIC Site <br />El Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site El Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool <br />VECTOR CONTROL PROGRAM (4000) <br />CI 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) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard El Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill El Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 1:1 Acute Care 0 Skilled Nursing CI Large Generator El Small Generator El Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 1:1 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 /> <br />Day Ph (925)787-4875 Night Ph <br />PROGRAM ELEMENT \ ‘00% FEE I ?O 0 Surcharge FEE 1:1 Other FEE <br />INSPECTOR # Or\saie 5 PERMIT VALID 7. 31• 23 to 2-- CI Food Handler/ Ttt.vr_ <br />'Kt Check # AMOUNT PAID Datel-)149 2-, INVOICE # <br />Cash REVIEWED BY ACCOUNTING OFFICE Date 1 "2,E) 2/3 <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <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 Spa 0 Out of Service Pool/Spa 1:1 Natural Bathing Area <br />0 Kennel <br />Krt <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) <br />El Chemical Toilets ----Numbeettafoitegto <br />vit AL-W DEPAg <br />0 Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />(4120) 0 Body Art <br />0 Body Art-Tem4vent MolidlhFacility (4131) <br />Faciii e <br /> <br />1UL 3 " 2 <br />Capacity tY043(4 <br />0 11 - 60 0 > 60 generators <br />CONTACT PERSON Stefanie Davis