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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Facility <br />Facility ID -,141-19-vivi- 2- T-(4- <br />aNew EH Program and New Facility <br />Pro9ram Record ID Pe.A)-D <br />ACCOUNTING OFFICE Cash REVIEWED BY <br />PROGRAM ELEMENT 1608 FEE 186 <br />INSPECTOR # 4589 PERMIT VALID <br />check # iS AMOUNT PAID <br />48-02-034 <br />/2.127 <br />1/23/13 <br />Other FEE <br />Food Handler <br />NVOICE # (‘) (e_ <br />4T Date el <br />MASTERFILE RE ORD INFORMATION PINK <br />El Surchar.eF <br />to 3 <br />Date <br />Facility Address 268 W LUCILLE AVE, MOUNTAIN HOUSE, CA, 95391 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />0 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 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 />0 Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event—Dates of operation from to • CFOO 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 />El Hazardous Materials Business Plan (1900) Number of chemicals: <br />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 />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 ----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 NPLJSEP Cleanup Site 0 UIC Site <br />0 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 <br /> <br />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 # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) 0 Dumpsters > 20 cu yd (4 of units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />0 Transfer Station 0 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 SHAHER BANO Day Ph 815-608-9402 Ni g ht ph 815-608-9402 <br />Capacity Vehicle # <br />Sludge/Ash Site <br />CIA Landfill Site <br />Farm/Ranch Cleanup Site