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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Pros ram at Existins Facilit <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 />Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 <br />0 Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />0 Retail Market----Square footage ID 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 />0 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 CI Special Event---Dates of operation from to Cl CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy CI Grade B Dairy CI Milk Dispenser -Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program Cl Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > CI CA (2232) CI CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />0 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 />CI Environmental Assessment CI UST-CAP Site CI Local HW Cleanup Site CI NPLJSEP Cleanup Site 0 UIC Site CI 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 CI Pool 0 Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />CI Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />0 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 Vehicle Registration # License # Capacity Vehicle # <br />CI Pumper Yard 0 Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill Cl Transfer Station CI Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility El Compost Facility CI Process/Recycle Facility 0 CIA Landfill Site <br />CI Refuse Vehicles (it of Units) 0 DUMDSterS > 20 cu yd (it of Units) CI Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator CI Limited Hauler <br />CI Transfer Station CI Veterinary Clinic CI Common Storage Facility CI 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 -ayne Jensen, Project Manager Day Ph 925-542-0646 Night Ph 925-542-0646 <br />PROGRAM ELEMENT 3612 FEE 141 <br />INSPECTOR # 4589 PERMIT VALID <br />Check # V /62k AMOUNT PAID <br />CI Cash REVIEWED BY <br />48-02-034 <br />1/2 3/13 <br />17 <br /> ay. friv e iq-10-1--1-ti. <br />1:1 Surch rge FEE CI Other FEE <br />to IA 31 D2x, 0 Food Handler <br />Date t INVOICE # <br />/Date <br />MASTERFILE R COR INFORMAINK <br />ACCOUNTING OFFICE