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CI Cash <br />REVIEWED BY <br />CI 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 />CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) El 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 />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 0 UST-CAP Site 0 Local HW Cleanup Site CI NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility CI Pool 0 Spa CI Out of Service Pool/Spa CI Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) CI 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 />Pumper Vehicle Registration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill CI Transfer Station <br />Waste Tire Facility CI Compost Facility <br />CI Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care Cl Acute Care 0 Skilled Nursing CI Large Generator CI Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 0 11 -60 CI > 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 /> <br />Day Ph 209 82-850 Night Ph 209-482-8508 <br />to <br />Dee <br />ACCOUNTING OFFICE <br />CONTACT PERSON <br />PROGRAM ELE <br />INSPECTOR # <br />CI Check # <br />sa Pe gig <br />I 6 FEE <br />PERMIT VALI <br />AMOUNT PAID <br />Other FEE <br />0 Food I-17dler <br />INVOICE # (24f17;F <br />Date <br />0 Ag/Cannery Waste Site <br />0 Process/Recycle Facility <br />CI Dumpsters > 20 cu yd (# of Units) <br />CI Sludge/Ash Site <br />0 CIA Landfill Site <br />CI Farm/Ranch Cleanup Site <br />New EH Pro ram at Existing Facili <br />Facility ID <br />ENew EH r ram an New Facil <br />Program Record ID (9) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Food Handlers Course required: YES CI No CI <br />OVending Machines Number of Units <br />0 Multiple Departments CI Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />DAIRY PROGRAM (2000) <br />CI Grade A Dairy <br />CUPA <br />CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />Facility Address 19394 Benedict Dr, Woodbridge, CA 95258 <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />CI Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage 0 w/Meat Market only <br />CI Mobile Food Vehicle --Make <br />Registration # <br />CI Mobile Food Prep Unit-- Make <br />Registration # Sticker # <br />Temporary Food Facility --Dates of operation from to CI Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to El CFO El A 0 B <br /> Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />PAYmENT. <br />RECENED <br />MAY 0 1 2024 <br />SAN jo4Qui,, _ouNTy <br />„ENVIFRop\i „1 ,,v,Y ._ AL <br />r"1/ALTH <br />RTMENT <br />1/23/13