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0New EH Program and N w Facility <br />Program Record ID 04 <br />El New EH Program at Existing Facility <br />Facility ID -fro 21-1 - <br /> <br />PROGRAM ELEMENT 3611 FEE <br />INSPECTOR # 4589 k PERMIT VALID iii /...;-0 .2.5 <br />CI Check # 1 9C (--p AMOUNT PAID 2, <br />El Cash Cash REVIEWED BY ACCOUNTING OFFICE <br />v 0-1 3qt-t 2_ 11/-7,(-24, <br />283 <br />to <br />Date <br />CI Surch rge FEE <br />A. 6/ <br />CI Other FEE <br />CI Food Handler <br />INvoicE # 3 o I <br /> l 227 AiDate <br />ASTERFILE R COR INFORMATION PINK 48-02-034 <br />1/23/13 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address 2596 Night Bloom Way, Lathrop, CA 95330 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />CI Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES CI No CI <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units <br />Cl Retail Market----Square footage CI w/Meat Market only CI Multiple Departments CI Prepackaged Goods Only <br />0 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 />Temporary Food Facility --Dates of operation from to Cl Ice Plant CI Produce Stand <br />Special Event---Dates of operation from to CI CFO CI A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program CI Program 1 Facility 0 Program 2 Facility CI 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 />CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI Hotel/Motel Number of Units CI 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 CI UST-CAP Site CI Local HW Cleanup Site CI NPL/SEP Cleanup Site Cl UIC Site <br />Abandoned HW Site El non-NPLJSEP Cleanup Site CI RWQCB Cleanup Site CI Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 1 0 Pool CI Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard ID Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />ID Landfill 0 Transfer Station El Ag/Cannery Waste Site <br />CI Waste Tire Facility CI Compost Facility 0 Process/Recycle Facility <br />CI Refuse Vehicles (# of Units) 0 Dumpsters > 90 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator CI Limited Hauler <br />Transfer Station 0 Veterinary Clinic CI Common Storage Facility 0 2 - 10 CI 11 - 60 0 > 60 generators <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 />CONTACT PERSON Layne Jensen, Project Manager Day Ph 925-542-0646 Night Ph 925-542-0646 <br />CI Milk Dispenser-Number of Containers in Multi-Head Unit <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />El Farm/Ranch Cleanup Site