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SATI JOAQUIN COUNIV ]',N r'IRO1` MENTAL HEALTH DEPARI'A111"N'T <br /> MASTERFILE REC01W INFORMATION F(DrOl — <br /> ❑New EH Program at Existing Facility �Pdcv GH Progr?m and <br /> Nw `acliy <br /> Irrat Record II)lm3 FacilittiD — <br /> ,� v <br /> facility Address�"IVI 711 iS A,,le. <br /> (Please Check the appropriate description and specify sire,number of units and pertinent information j <br /> FOOD PROGRAM(1000) <br /> ❑RestaurauL Seating Capacity Square Footage Food IIandlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ Mali Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make_ Vehicle Type Color <br /> Registration# License# Slicker it <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Erenrpl Syslent (2299) <br /> ❑ CRT Offsite IIandlers(221E) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered I'errni(ling facility — ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pemut-By-Rule household Hazardous Waste <br /> ❑ ABMT,GROUI1D STORAGE TANK FACILIT a(AST)(2390) ?dumber of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and R(ursrs <br /> I10USING PROGRAM(2400) <br /> ❑ Ilo(enj lotel Number of Units ❑ .Jail or Exempt Institution--Number of Units <br /> Employee Ho using-(2700) Use EtrrploreeI Ifousinc/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTIOU CON T ROL(3000) <br /> ❑ EaAroumental Assessment ❑ UST-CAP Site ❑ Local MV Cleanup Site. ❑ NPLlSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IM'Site ❑ non-NPLlSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remedia(ioa Site <br /> %RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Scrti!ce Pool/Spa ❑ i Wural Bathing Arca <br /> VECTOR COt.ITROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Fennel <br /> TATTOO 130DY PIERCING,PERMANENT COSNIETIC PROGRAM(4100) <br /> ❑ Tattooing(4 12 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle-Registration# — License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets dumber of Units <br /> SOLID VIASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag!Cannery Waste Site ❑ Sludge/Mh Site <br /> CK Waste Tire Facility ❑ Compost Facility ❑ ProcessfRecycle Facility ❑ CIA,Landfill Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>2.0 cu yd —Number of Units ❑ Farm/Rauch Cicaoup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Circ ❑ Acute Care ❑ Skilled Hursing ❑ Large Generator ❑ Small Generator ❑ Limited ltauler <br /> ❑ Transfer Sialion ❑ Veterinary Cliuie ❑ Common Storage facility-----❑ 2- 10--❑ 11 -60--- ❑ ~60 gcnrralors <br /> PUBLIC'NATEZ S'i'STf=M PROGRAM(4600) Clc ill';i a lff)16-02-0oJ Bloc Applicarioit F-urru <br /> Er1iERG`VCY 640 T trtcAT torr FOR T lrr5 b ACILI o'Y ,arlDlor,F RGC-IRA .'l <br /> CONTACT T'1;l:.SON Day Ni Night Ph <br /> I'RuG20II;LMGI;T �1'A Fi:r- -I[/ — 1-:1surcharg'FEE -f-- ❑ Other FEF <br /> -T <br /> 1risrF.(-roR4 , I'[I,f,uT',`i:LID tar -- ❑ Food IIandlcr --- <br /> - _ <br /> r <br /> – <br /> Ll t.l �1.r7 r�Arrlt,i,t1;,.;•,� ;_;it,, I.t,rr�lr 1?,l �- -- <br /> ❑ (-, li r <br /> tt ''rf ' ;Tll3(11'PDC <br /> _ �__-� -_ - --------_ --- --- — --- 1. <br />