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0 Milk Dispenser -Number of Containers In Multi.Head Unit <br />0 Kennel <br />'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Nihv ri I Pinokite rri Existing Facility aiNt" rt xram a Now Facility <br />Facility ID rthirtiZ7 Program Record ID K VD22:71 <br />Facility Address 472 W San Juan Cl, Mountain House,California -95391 <br />(Ploaso chock the appropriate description and specify size, number of uotte and pertinent information.) <br />i000 PROGRAM (1600) <br />o Restaurant Seliti.iri Capecily Siiki rue Footage Food Handlers Course reetlired 'Oh 0 No 0 <br />Commissary 0 Dry storage only 0 wth Food Preparation ElVending Machines Number of Unils <br />Retail Mal ket-• -Square loolap 0 wiMeot Mal ket wily 0 Departnienth 0 Prepai;kaged °taxis Only <br />Mobilo Food Vehicle --Make Vehicle Typo Color <br />Regzslration license I/ <br />Mobile Food Prep Unit-. Mak.5 Vehicle Type Color <br /> Reoctratron License # Stickcr <br />Temporary Food Facility --Dales of open:aeon from to Plant 0 Produce Stand <br />ID special Event...norer; of operation from to CFO al 0 B <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy 0 Grade B Dairy <br />CUPA <br />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)--------> -Torts Generated Per Year <br />Tiered Permitting Facility El CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR BMW (22.36) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and forms <br />0 Other CUPA Program <br />Lishturilej (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2/00) U. rmployee Housing/labor Camp APPlication romr, <br />SITE MITIGATION (2900) lINDFRGROUND 0,W 4cTION CONTROL (300(1) <br />Environmental Assessment 0 UST-CAP Site ID Local 11W Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned MW Site El non•NPUSEP Cleanup Site 0 RWOCB Cleanup Site 0 Water Quality Remedintion Site <br />RECREATIONAL HEikijitPrlogiltAm (3600) <br />Number of PuolhiSpas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VLC TOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum numb-or of birds <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.Starllization (4121) 0 Body Art Temp Event Co•ord (4130) 0 Body Art-Temp Event Mobile Facility (4131 <br />!Num WASTE FRO0RAM.(4200) <br />Pumper VehicleHr-eirsIration 1) Llec9so # Capacity kriehicle 0 <br />Pumper Yard CI Package Treatment Plant ChetIlIcal Toilets -••-Number <br />of orlis <br /> <br />MAP_WA§IE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Si <br />Waste Tiro Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Land <br />Refuse Vehicles r , Durnpstors > 20 cu yd ircruou U Farm/Ran <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Caro 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator U Limited Neu <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 D 11 • GO 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) use pkvs EHD 46-02-003 13lue Application Form <br />EFAERGINCY NOTIFICATION FOR TFIlb FACILITY AND/oe PROGRAM <br />CONTACT PERSON Supriya Santhilal rktY Ph 9256219492 NujliIPh 9256219492 <br />PROGRAM ELEMENT \ \OdCer FEE k ?)(z) — 0 Surcharge FEE . D Other FEE <br />INSPFGTOR # V-- L— PFRmiT VALID S ' \ ' 2 Li to `---k - SO. ZS" 0 Food H;19{ <br />chuck g AMOUNT PAID Dale INVOK:E # rei ) 0 -7- <br />ca.„1,, RUM_ WU) I3Y ACC:01.114r1r433 Orr-IM Diltfl <br />46 Oi <br />1/25P I.! Wo1 /4,c0a8\cA <br />MA!, T Lin la l4Etant0 0,INIA I 101,1 liNk