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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM RF yMFNT ❑ New EH Program at Existing Facility ew EH Program and New FacilityCE/VED Facility ID Program Record ID 5- F?Y 11 juz 0� Facility Address 19699 South Mountain House,Mountain House CA 95391 S'4 vjp2022 /gQU/N (Please check the PROGRAM(1600)appropriate description and specify size, number of units and pertinent information.) HFALTl1 pEp RTM LNTy A 8 Restaurant: Seating Capacity 41 Square Footage 2,361 Food Handlers Course required: YES❑ No ❑ENT ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units 0 Retail Market—Square footage El With Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) -------0 Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility----- IJ Conditionally Authorized(CA) 0 Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste 0 ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700)Use Employee Housing/Labor Cama Apolication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site 0 RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility 0 Pool 0 spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-----Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing (4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# 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 0 Compost Facility 0 ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Mary Her Day Ph 206-318-8705 Night Ph PROGRAM ELEMENTIII, IIQZ � - FEE S»7— ❑ Surcharge FEE ❑ Other FEE INSPECTOR# L PERMIT VALI —I- b- Z 2 t0 -7-5 - 2 Z ❑ Food Handier y ElCheck# Imo- AMOUNT PAID &is .3 0D Date 7 7 zy INVOICE# 08 21 1 11 Cash /RTEvEW/EDBY L'4/ ,IACCOUNTINGOFFICE Date 7//0-2- 48-02-034 ��yl,l-, 4N3`gW-^!g MASTERFILE RECORD INFORMATION PINK 11/15/07 `1 rrl III