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Facility Address 2350W Kettleman Lane, Lodi, California, 95242 <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 <br />Commissary 0 Dry storage only CI with Food Preparation <br />Retail Market----Square footage 15,000 (300 for r-I .__. w/Meat Market only <br /> <br />0 Mobile Food Vehicle —Make food)Vehicle Type <br /> <br />Registration # License # <br />CI Mobile Food Prep Unit-- Make Vehicle Type <br /> <br />Registration # License # 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 0A0B <br />Food Handlers Course required: YES 0 No 0 <br />:Wending Machines Number of Units <br />0 Multiple Departments E Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />PA YMEW T <br />RECE/ VED <br />FEB 09 2024 <br />SAN JOAQU/N COUNTY' <br />ENVIRONMENTA L <br />HEALTH DEPARTMENT <br />Docuign Envelope ID: 81A9FA42-1C09-4967-9DC7-646832CC4231 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existing Facility ew EH Program and New Facility <br />Facility ID CO2-K14.2— Program Record ID 1g-D5+0.5-.. <br />PROGRAM ELEMENT 1618 FEE 287 <br />INSPECTOR # 9838 PERMIT VALID <br />tCheck # 106 /6572_1 AMOUNT PAI <br />Cash REVIEWED BY ACCOUNTING OFFICE <br />0 Surcharge FEE <br /> <br />to 3 / .26 <br />Date <br />CI Other FEE <br />I=1 Food Handler <br />INVOICE # <br />Date <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI 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) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) <br />CI 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 />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 0 UST-CAP Site CI Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site CI 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 CI Pool 0 Spa <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />CI 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 />CI Pumper Vehicle Registration # <br /> <br />License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant <br /> 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station El Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility O Process/Recycle Facility <br />Refuse Vehicles (# of Units) <br /> O Du mpsters > 9 0 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care CI Acute Care CI Skilled Nursing CI Large Generator CI Small Generator CI Limited Hauler <br />CI Transfer Station 0 Veterinary Clinic CI Common Storage Facility CI 2-10 0 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 /> <br />Day Ph 215-867-0791 Night Ph <br />48-02-034 MASTERFILE RECORD IN -11RM TION PINK <br />0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />CI Sludge/Ash Site <br />CI CIA Landfill Site <br />El Farm/Ranch Cleanup Site <br />CONTACT PERSON Heather Spohn <br />1/23/13