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} SAVJOAQUII`I COU1`iTY IsNsr'IRUNT,(GN`I'AL HEALTH llLI'AI?'1'1\TLI`ii' <br /> RJB INFORMATION FOM <br /> I�'IASTF,RFILT;RECO <br /> ❑New EH Program at Existing Facility facer El l Program and New hZcilil}_ <br /> Facili(1'ID _®_® Pry rani Record <br /> Facility Address _TSC <br /> (Please Check the appropriate description and specify size,number of units and ftertinenl information.) <br /> 1=00D PROGRAM(1000) <br /> ❑ Restaurant: Seating Capacity Square Footage Food IIandlers Course required: YES El No El <br /> ❑ Commissary ❑ Dry storage only ❑ Mth Food Preparation ❑Veading Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Paeat I\4arket only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License 4 Slicker 9 <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker 4 <br /> ❑ Temporary Food Facility--Dates of operalion from to ❑ Ice Plant <br /> ❑ Special Eveat --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeaser--Number of Containers in Paulo-head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑hazardous Waste generator--- 'rons Generated Pec Year ❑ Recycle I Eienipl Sys(em(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Reeyclers(2217) <br /> Tiered I'ermi(ting J<acili(y ❑ Conditionally Authorizcd(CA) ❑ Conditionally Excmpt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ I'emut-By-l-Wie household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Nun-tbcr of AST <br /> UNDERGROUND STORAGE TANK(US l7 PROGRAM M(2300)Use UST A and F rorors <br /> HOUSING PROGRAVA(2400) <br /> ❑ no(efht Iotel Number of Units ❑ Jail or Exempt Institution--Nurnbcr of Units <br /> Employee housing(2700) Use}rrpfapee Ifousine/Lahvr Camp Appficafiort FOrnr <br /> SITE MITIGATION(2900) UNDERGROUND IPIJECTI014 CONTROL0000) <br /> ❑ EnAronmental Assessment ❑ UST-CAP Site ❑ Local LIN C'leauup Site. 11NPLlSEP Cleanup Site 11UIC Site <br /> ❑ Abandoned IM'Site Elnon-NPLISEP Cleanup Site 11rwQCB Cleanup Site 11Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number ofPooWSpas at Facility ❑ fool ❑ Spa ❑ Out of Scnice PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Ta(tooing(412 1) El Body Piercing(4120) ❑ Perruaneat Cosmetics(4122) <br /> LIQUID WASTE PROGRAFA(4200) <br /> ❑ Pumper Vehicle-Registration# — License H Capacity Vehicle 0 <br /> ❑ Pumper Pard ❑ Package Treatment Plant ❑ Clteaucsl Toilets 1,1umlxr of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Traasfer Station ❑ Ag/Cannery Wase Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facilil}' ❑ CIA Landfill Site <br /> Refuse Vehicles—plumber of Units ❑ Dumpsters>2.0 cu yd —11 umber of Units ❑ FarnJP_loch Clcaoup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care C1Acute Care 111Skilled Nursing ❑ Large Generator ❑ Small Generator El Limited Hauler <br /> ❑ Transfer Sfaiion ❑ Veterinar}'Clinic ❑ Cammoa Sturaee I rcility- --❑ 2- ]0--❑ 11 -GO---E 00 gencralors <br /> PUBLIC WATER S-3'S F'EM PROGRAM(4000) Us:!'(I;S ETIP MP-32-003 17-01 nr <br /> IErAGRGErtCY 8--Io-i tCtcia IoFi t-Gr;s ms FACILI—Cf altoloa PROGRAM <br /> CONTACT PIa:SON Day Hi - ---- — 114ir..ht Pit <br /> I'ROi;tL•11ti1 I;Ll:nlr_r:T= v`�u� _ p'Lc —�/ --_ ❑ Surci,lrl c 1 F_;- - ❑ Ottrcr z er _ <br /> trysrF.(-roa'1 � 111:1-•Atll-',rAUD to ---- ❑ food IlandlQr _—__ <br /> D.) I IIJt1D 1 _ <br /> ❑ ("a:h f'_C"i Ci+� 1\ I f\�_�. �'_ii Tit 3(j IT I,:C <br />