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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD LJ New EH Program at Existing Facility ElNew EH Program and New Facility Facility ID fA6( 2-i&o/D Program Record ID & wm<�� Facility Address ( U I L W , trod; LIVe Lodi CIEJ �j4L (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) RFC �� r Mqy 0 1�e��7��AI �0��?y gRrM�Nr ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color FEE Handler Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker# ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in MultkHead Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility 1111Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year 11 Tiered Permitting Facility--- .... > 11 CA (2232) 11 CE (22331 22341 2235, 2237) 1:1 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms 1:1 Other CUPA Program Program 3 Facility 11 PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ HotellMotel ------ Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool ❑ VECTOR CONTROL PROGRAM (4000) 11Mm Poultry Farm -------aximunumber of birds Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body actitioner Reg t So anneal USPS Notification (4115) moody Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles Nofunits) ❑ Dumpsters> 20 cu yd I# of Units/ ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON vl1AK VC�fi Day PhZPq Z6�-7NS 4 Nigh[ Ph LOh - L407' /7 WILLI J �-- PROGRAM ELEMENT NI.1� FEE INSPECTOR#g,194 PERMITVALID 6fJ 22 ❑Surcharge FEE t0 �P307_Z ❑Other 11Food FEE Handler ❑ Check# #Cash AMOUNT PAID REVIEWED BY / Wv ACCOUNTING Date S�3 2-- OFFICE /j .,� INVOICE# 3� U7/�.-�— Date 512_41142- Z 12-