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ENew EH Program andq ew Facility <br />Program Record ID p , CV <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />0 Kennel <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID <br />New EH Program at Existing Facility <br />aktin0 h3° <br />Facility Address 16480 Golden Valley Pkwy. Ste. C. Lathrop, CA 95330 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />El Restaurant: Seating Capacity Square Footage -1500 <br />LI Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units 0 <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make <br /> Vehicle Type Color <br />Registration # <br /> License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0 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 0 Program 1 Facility 0 Program 2 Facility <br />Hazardous Waste Generator (2200) > -Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution <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 El Local HW Cleanup Site 0 NPL/SEP Cleanup Site LI UIC Site <br />Abandoned HW Site 0 non-NPL/SEP 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 <br />VECTOR CONTROL PROGRAM (4000) <br />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) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />Food Handlers Course required: YES g No 0 <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />1=1 Special Event---Dates of operation from <br />0 Program 3 Facility <br />0 PBR (2231) 0 PBR HHW (2236) <br />----Number of Units <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # <br />Pumper Yard <br /> <br />0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skille <br />Transfer Station 0 Veterinary Clinic <br />0 Chemical Toilets ---Number of Units <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site <br />License # Capacity Vehicle # <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />Dumpsters > 20 cu yd (# of Units) 1 <br />d Nursing LI Large Generator LI Small Generator 0 Limited Hauler <br />0 Common Storage Facility 0 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 />CONTACT PERSON Maria Martines-District Manager Day ph 801-268-3400 Night Ph <br />PROGRAM ELEMENT\ \62,. tf__.) FEE --ThTh (1_ N - 0 SUrrhnrge FFF 0 Other FEE <br />INSPECTOR # V- L. PERMIT VALID ' k P.? \--A - <br /> <br />to '..- • ..23 0 Food Handler <br />Check # AMOUNT PAID Date INvoicE # <br />Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />z 3-11caq. ANt: An4-00453S