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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility ONew EH Program and New Facility <br /> <br />Facility ID F--,460.2.75-‘,. Program Record ID MD,91-g2/( <br />Facility Address 302 N Sacramento Street Lodi, CA 95242 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />2 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 12 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation :Wending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />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 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CUPA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI 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) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />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 />Hotel/Motel Number of Units 0 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 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPLJSEP 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 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <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) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />MEDICAL WASTE PROGRAM (4500) <br />0 Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator <br />Transfer Station 0 Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />0 Common Storage Facility 0 2 - 10 <br />0 Process/Recycle Facility <br />0 Dumpsters > 20 cu yd (# of Units) <br />0 Small Generator OrLjoited a <br />0 11 - 60 <br />0 SiudgemosAhliitIve <br />CIA Laridt ,ajte <br />Farm/R <br />SAN j <br />th93 2epets <br />c4" %tett e <br />ECE <br />0 Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ENV/R COUN 14r., Ty <br /> <br />Day ph 209.481.8981 Night Ph 2097mmEm 44v ppbpLu, ...4 TAL <br />--rnar mete <br />2 24- — 2-3 to 2-e1 2 <br />0 Food Handler <br />INVOICE # 37g 62_ <br />Date .2_ 23 <br />48-02-034 <br />1/23/13 -4234t,--- see ins)ec/i-i CL <br />INFORMATION dASTE.RFILE RECORD FORMATION PINK <br />CONTACT PERSON Yousef Haddad <br />PROGRAM ELEMENT 16) 2.4a FEE <br />INSPECTOR # CA- r, 4\... PERMIT VALID <br />E(Check # 2. AMOUNT PAID <br />Cash REVIEWED <br />F . Date <br />ACCOUNTING OFFICE <br />Surcharge FEE 0 Other FEE