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El Surchar e F E 0 Other FEE <br />to 1 2— ID Food Handler <br />INVOICE # 3 <br />Date <br />, SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />El New EH Program at Existing Facility IDNew EH Program and New Facility <br />FacthtD F.4O Program Record ID <br />Facility Address 2611 Reynolds Ranch Pkwy, Lodi, CA 95240 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity 37 Square Footage 4003 <br />Commissary CI Dry storage only 0 with Food Preparation CIVending Machines Number of Units <br />Retail Market----Square footage CI w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make <br />Vehicle Type <br />Registration # <br /> <br />License # <br />Cl Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />CI Temporary Food Facility —Dates of operation from to <br />CI Special Event---Dates of operation from <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: -- <br />El CalARP Program CI Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) El PBR HHW (2236) <br />CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs _ <br />El Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 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 />ID Environmental Assessment ID UST-CAP Site CI Local HW Cleanup Site 0 NPLJSEP Cleanup Site Cl UIC Site <br />El Abandoned HW Site 0 non-NPUSEP 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 />Poultry Farm Maximum number of birds <br /> <br />0 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />CI Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI 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 />0 Pumper Vehicle Registration # License # <br />CI Pumper Yard CI Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station CI Ag/Cannery Waste Site 0 Sludge/Ash Site <br />CI Waste Tire Facility 0 Compost Facility CI Process/Recycle Facility CI CIA Landfill Site <br />CI Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator 0 Limited Hauler <br />Transfer Station CI Veterinary Clinic 0 Common Storage Facility CI 2 - 10 CI 11 - 60 0 > 60 generators <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 ank Rodri, urx Day Ph 2094780234 Night Ph 2093512283 <br />_ <br />PROGRAM ELEMENT \ FEE <br />INSPECTOR # PERMIT VALID <br />Check # V S5C---"" AMOUNT PAID Date <br />Cash REVIEWED BY LCAO(Ck ACCOUNTING OFFICE <br />48-02-034 <br />1/23/13 1-73 -7 <br />MASTERFILE RECO D INFORMATION PINK <br />8441s jOAQui <br />NO,EP 2NI 2 <br />RECEIVED <br />3T <br />HEALTH DE ENTAL TY <br />Food Handlers Course required: yEsP leillTdvEl <br />Color <br />Sticker # <br />Color <br />Sticker # <br />0 Ice Plant El Produce Stand <br />1171 CFO 0 A 0 B <br />0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> Capacity Vehicle #