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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM CiNew EH Program and New Facility Program Record ID eRtASLI—Eigli Facility ID PAYmE NT RECEivE D FEB 21 2024 0 New EH Program at Existing Facility SAN JOAQUIN COUNTY HEALTH ENVIRONMENTAL DEPARTMENT Facility Address 559 E Arnaudo Blvd. Mountain House (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES 0 No 0 Commissary 0 Dry storage only 0 with Food Preparation CIVending Machines Number of Units Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 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 0 Ice Plant 0 Produce Stand Special Event---Dates of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) Grade A Dairy 0 Grade B Dairy CI Milk Dispenser -Number of Containers in Multi-Head Unit CUPA 0 Hazardous Materials Business Plan (1900) Number of chemicals: CalARP Program CI Program 1 Facility 0 Program 2 Facility CI Program 3 Facility Hazardous Waste Generator (2200) >- Tons Generated Per Year CI Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms CI Other CUPA Program HOUSING PROGRAM (2400) Hotel/Motel Number of Units 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPLJSEP Cleanup Site 0 UIC Site 0 Abandoned HW Site 0 non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 0 Pool 111 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds 0 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) Landfill CI Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site Refuse Vehicles (# of Units) 0 Dumpsters > 20 Cu yd (# of Units) 0 Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 CI 11 - 60 0 > 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 Deborah Hull Day Ph 510-209-5585 Night Ph PROGRAM ELEMENT 3612 FEE 141 El Surcharg FE CI Other FEE INSPECTOR # 4589 PERMIT VALID 2h-t(2-4- tO 1213/ CI Food Handler 1:1 Check # Vi-SG-- AMOUNT PAID 44t 11+1. 06 Date INVOICE # 3q -7 5 1 Cash REVIEWED BY ACCOUNTING OFFICE Date sh1/2-"/ 48-02-034 1/23/13 064). 4 I -7 6, g_S -•-7 MASTERFILE RECORD INFORMATION PINK