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Facility Address 413 E. Lockeford St., Lodi, CA 95240 <br />(Please check the appropriate description and specify size, number of units and pprtinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary CI Dry storage only 0 with Food Preparation <br />Retail Market----Square footage CI w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />CI Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />Temporary Food Facility --Dates of operation from to <br />El Special Event---Dates of operation from May 23 to <br />Food Handlers Course required: YES CI No CI <br />OVending Machines Number of Units <br />CI Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br /> 0 Ice Plant CI Produce Stand <br />May 27 0CF0 DADE <br />AfAR 2 7 <br />2024 SA N jai <br />N/144j/Al COUN 11 •41/... N4,7,N7. , <br />R 7-Q.siv <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />CI New EH Program at Existing Facility <br />Facility ID A a(DAT 12-3 Program Record ID RD5+10/1 <br />New EH Program and New acility <br />0 Other FEE <br />0 Food Handler <br />INVOICE # <br />Date y.7.2/2.. <br />MASTERFILE OR INFORMATION PINK <br />El Surchar e FE <br />to <br />Date <br />El Cash REVIEWED BY ACCOUNTING OFFICE <br />PROGRAM ELEM <br />INSPECTOR # <br />CI Check # <br />FEE <br />PERMIT VALID <br />AMOUNT PAID <br />48-02-034 <br />1/23/13 I 7 42-g3 I 2-37 <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />CI Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />El CalARP Program CI Program 1 Facility CI Program 2 Facility CI Program 3 Facility <br />CI Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) CI CE (2233, 2234, 2235, 2237) CI PBR (2231) 0 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 />CI Other CUPA Program <br />HOUSING PROGRAM (2400) <br />CI 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 CI UST-CAP Site 0 Local HW Cleanup Site El NPL/SEP Cleanup Site CI UIC Site <br />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 0 Pool 0 Spa CI Out of Service Pool/Spa CI 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 />CI 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 />CI 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 />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />CI Waste Tire Facility 0 Compost Facility Cl Process/Recycle Facility <br />CI Refuse Vehicles (# of Units) 0 Dumpsters >20 cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />CI Primary Care CI Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station CI Veterinary Clinic 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 Mark Landon Day Ph 909-986-7502 Night Ph 909-986-7502 <br />0 Sludge/Ash Site <br />CI CIA Landfill Site <br />CI Farm/Ranch Cleanup Site