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SAN J-GOA.I-QUIP1 COUNTY' 7I sZOI lMENTAL HEALT-11 DETARTAI ENT <br /> MASTERFILE R-E,CORD INFORMATION FO101 <br /> 0 New Eli Program at Existia-Facility ;6*;N:(Ell Program and NeIT Faffli(Y <br /> I+acilify�ILDf�0 <br /> Facility Address -7 42-1 e-02 h e-C_ kvl Lei q5diO <br /> (Please Check the appropriate description and specify sLt7.e number ofunits and perliaent information.) <br /> FOOD PROGRAM(1600) <br /> 0 Res1auraat: Seating Capacity_ Square Footage Food Handlers Course required: YESEI NoEl <br /> El Commissary El Dry storage only 0 with,Food Preparation ElVending Machines—Number of Units <br /> El Retail Market—Square Footage 0-widi lvleat Market only El Multiple Departments El Prepackaged Goods Only <br /> El Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration 9 License 4 Sticker it <br /> El Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration X License iq Sticker'�, <br /> El Temporary Food Facility--Dates of operation from to El Ice Plant <br /> El Special Ewat —Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM (2000) <br /> 11 Grade A Dairy El Grade B Dairy [I Milk Dispenser--Nunibcr of Container in Multi-licad Unit <br /> CUPA El State Facility Surcharge(2399) <br /> HAZARDOUS iVASTE PROGRAM 2200) <br /> El hazardous Waste Generated Per Year El Recycle I Eienipt System(2299) <br /> El CRT Offsite Handlers(2219) El Silver Only(2222) El Appliance Recyclers(2217) <br /> Tiered Icraiitting Facility El Conditionally Authorized(CA) 0 Conditionally Exempt(CE) <br /> El <br /> Permit-By-Rule Fixed Unit El P em,-dt-By-Rulc Household Hazardous Waste <br /> EJ ABOVEGROUND STORAGE TANK FACILITY(AS!)(2390) ?dumber o[AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and-B f-aFfIrs <br /> HOUSING PROGRAM(2400) <br /> 0 llotcnlo(el—Number of Units ❑ Jail or EKempt Institution--plumber of Units <br /> E.mptoyee 110usiagg(270) Use Entp[olve <br /> SITE WIlTiGATION(2900) UNDERGROUND D4JECTION CONTROL(3000) <br /> [I EnAroamca(alAssessnieat El UST-CAP Site El Local IM Cleanup Site 11 NPIJSEr Cleanup Site El uic site <br /> El Abandoned MY Site El non-NMISEP Cleanup Site El 11,"W?CCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of ools/Spas at Facility El Pool El Spa El Out of Ser)-ice rooUSpa E) Natural Battling Area <br /> VECTOR Goll TROL, PROGRAM(4000) <br /> El Poultry Farm—Maximum number of birds El Kennel <br /> TArT00, 13ODY PIERCING,PERf,AAHEHT COSMMC PROGRAM(4100) <br /> El Tattooing(412 1) 0 Body Piercing(4120) 0 per-manent Cosmetics(4122) <br /> LIQUID WASTE P RO G RAP-il(4 200) <br /> 0 Pumper Vehicle-RegiTL-,L'ion-ft License# Capacity Vehicle 9 <br /> 0 Pumper Yard 11 'racLage Treatment Plant- El Chemical Toilets—Number of Units <br /> SOLID WAST E PROGRAM(4400) <br /> 0 La a d fit U El Trausfer Station. 0 Ag I Cannery Waste Site 1-1 Sludge/Ash Site <br /> Fl-waste'Fire Facility El Compost Facility El ProcessfRecycte Facility El CIA Landfill Site <br /> El Refuse Vehicles-Number of Units ❑ DumpSters>20 cu yd —Number of Units El FarmJR-111ch c[cqaup Site <br /> MEDICAL VIASTE PROGRAM(4500) <br /> El Primary Care F1 Acute Care El Skilled NlursLuv El Large Generator 0 Small Generator 0 Limited Hauler <br /> L <br /> El Transfer Sta(ion ❑ Vcteriaary Clinic El coninjon Storage Facility--El 2- 10--El I I -60 generators <br /> PUBLIC%1fATER SYSTEM PROGRAM(4600) Use FifS FfID f6-02-003 B'1vc,,1j)L21iC(r(i011 F-ui T/I <br /> r;-:r.,iERc-a.1cY Ho-t IricP-mli fort sills FACILITY ANDIOR F ROGRAM <br /> CONT ACS'PERSON Day P11 Night Ph <br /> J'Ro(31tA11IELFNIENT 4'/72YC> FclF D ,--,ucchargQ El Other FEE <br /> IrqSrF.C-T0,:?',4 c262-0 _1_1F[Q,11TV,,+L1E1 0 Food Handler—_ <br /> El <br />